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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/gynecologyabdomi02kell 


AUTHORS. 


Brooke  M.  Anspach,  M.D. 
J.  M.  Baldy,  M.D.  ^ 
J.  C.  Bloodgood,  M.D. 
Henry  T.  Byford,  M.D. 
John  G.  Clark,  M.D.» 
George  M.  Edebohls,  M.D. 
John  M.  T.  Finney,  M.D. 
William  W.  Ford,  M.D. 
Antsta  M.  Fullerton,  ^I.D. 
Fern  AND  Henrotin,  M.D. 
Barton  Cooke  Hirst,  M.D. 
Guy  L.  Hunner,  M.D. 
Elizabeth  Hurdon,  M.D. 
George  Ben  Johnston,  M.D. 
Howard  A.  Kelly,  M.D. 

J.  Whitridge 


Beverly  MacMonagle,  M.D. 
Edward  Martin,  M.D. 
Floyd  W.  McRae,  M.D. 
G.  Brown  Miller,  M.D. 
B.  G.  a.  Moynihan,  M.S. 
John  B.  Murphy,  M.D. 
Charles  P.  Noble,  M.D. 
Richard  C.  Norris,  M.D. 

A.    J.  OCHSNER,  M.D. 

Eugene  L.  Opie,  M.D. 
James  F.  W.  Ross,  M.D. 
Alexander  J.  C.  Skene,  M.D. 
Stephen  H.  Watts,  M.D. 
J.  Clarence  Webster,  M.D. 
X.  0.  Werder,  M.D. 
Williams,  M.D. 


GYNECOLOGY 


AND 


ABDOMINAL  SURGERY 


EDITED  BY 


HOWARD  A.  KELLY,  M.D.,  F.R.C.S.  (hon.  edin.) 

PROFESSOR    OF    GYNECOLOGIC    SURGERY    AT    THE    JOHNS    HOPKINS    UNIVERSITY;    GYNECOLOGIST 
TO  THE   JOHNS   HOPKINS    HOSPITAL,   BALTIMORE 


AND 


CHARLES  P.  NOBLE,  M.D.,  S.D. 

CLINICAL    PROFESSOR    OF    GYNECOLOGY    AT    THE    WOMAN'S    MEDICAL    COLLEGE,    PHILADELPHIA; 
SURGEON-IN-CHIEF,    KENSINGTON    HOSPITAL    FOR   WOMEN,    PHILADELPHIA 


Illustrated  by  Hermann  Becker 
Max  Brodel  and  Others 


VOLUME  TWO 


PHILADELPHIA  AND   LONDON 

W.   B.   SAUNDERS    COMPANY 

1  908 


Copyright,  1908,  by  W.  B.  Saunders  Company 


PRINTED     IN     AMEPIC* 

PRESS     O  F 

B.     SAUNDERS     COMP 

PHII_ADE  l_PHIA 


AUTHORS  OF  VOLUME  II. 


BROOKE  M.  ANSPACH,  M.D Philadelphia.  Pa. 

Gynecologist  and  Obstetrician  to  the  Philadelphia  Hospital;  Assistant  Gynecologist  to  the 
University  Hospital;  Instructor  in  Gynecology,  University  of  Pennsylvania;  Pathologist 
•  to  the  Kensington  Hospital  for  Women,  Philadelphia. 

JOSEPH  C.  BLOODGOOD,  B.S.,  M.D Baltimore,  Md. 

Associate  Professor  of  Surgery,  Johns  Hopkins  University;  Associate  Surgeon,  Johns  Hoi> 
kins  Hospital;  Chief  Surgeon  to  St.  Agnes'  Hospital. 

JOHN  M.  T.  FINNEY,  A.B.,  M.D Baltimore,  Md. 

Associate  Professor  of  Surgery,  Johns  Hopkins  University. 

BARTON   COOKE   HIRST,    A.B.,    M.D Philadelphia,  Pa. 

Professor  of  Obstetrics,  University  of  Pennsylvania;  Gynecologist  to  the  Howard,  the  Ortho- 
pedic, and  the  Philadelphia  Hospitals. 

GUY  L.  HUNNER,  B.S.,  M.D Baltimore,  Md. 

Associate  in  Gynecology,  Johns  Hopkins  University;  Professor  of  Genito-urinary  Diseases, 
Woman's  Medical  College  of  Baltimore;  Visiting  Gynecologist,  St.  Agnes'  Hospital  and 
Hebrew  Hospital,  Baltimore;  Frederick  City  Hospital,  Frederick,  Md.;  Consulting  Gynecol- 
ogist, Brattleboro  Memorial  Hospital,  Brattleboro,  Vt. 

ELIZABETH  HURDON,  M.D Baltimore,  Md. 

Assistant  in  Gynecology,  Johns  Hopkins  Hospital,  Baltimore. 

GEORGE  BEN  JOHNSTON,  M.D Richmond,  Va. 

Professor  of  Abdominal  Surgery  in  the  Medical  College  of  Virginia;  Chief  of  Staff  and  Surgeon 
to  the  Memorial  Hospital;  Surgeon  to  the  City  Home. 

HOWARD  A.  KELLY,  A.B.,  M.D.,  LL.D.,  F.R.C.S.  Hon.  Edin.  .  .  Baltimore,  Md. 
Professor  of  Gynecological  Surgery,  Johns  Hopkins  University;  Gynecologist  to  the  Johns 
Hopkins  Hospital,  Baltimore. 

EDWARD  MARTIN,  A.M.,  M.D Philadelphia,  Pa. 

Professor  of  Clinical  Surgery,  University  of  Pennsylvania;  Professor  of  Clinical  Surgeiy, 
Women's  Medical  College,  Philadelphia;  Surgeon  to  the  Howard,  the  Philadelphia,  and  the 
University  Hospitals. 

FLOYD  W.  McRAE,  M.D Atlanta.  Ga. 

Professor  of  Gastro-intestinal,  Rectal,  and  Clinical  Surgery,  Atlanta  College  of  Physicians 
and  Surgeons;  Surgeon-in-Chief  to  the  Piedmont  Sanatorium;  Visiting  Surgeon  to  the  Grady 
Hospital,  the  Wesley  Memorial  Hospital,  and  St.  Joseph's  Infirmary. 

G.  BROWN  MILLER,  B.S.,  M.D Washington,  D.  C. 

Gynecologist  to  the  Emergency  Hospital;  Associate  Gynecologist  to  the  Columbia  Hospital 
for  Women;  Instructor  in  Gynecology  in  the  George  W^ashington  University. 

B.  G.  A.  MOYNIHAN,  M.S.,  F.R.C.S Leeds,  England. 

Honorary  Surgeon,  Leeds  General  Infirmary,  Leeds,  England. 

iii 


IV  AUTHORS    OF   VOLUME   II. 

JOHN  B.  MURPHY,  A.M.,  M.D.,  D.S.C.,  Eng.,  LL.D Chicago,  III. 

Professor  of  the  Principles  and  Practice  of  Surgery  and  of  Clinical  Surgery  and  Head  of  the 
Department  of  Surgery,  Northwestern  University  Medical  School. 

CHARLES  P.  NOBLE,  M.D.,  S.D Philadelphia.  Pa. 

Clinical  Professor  of  Gynecology,  Women's  Medical  College ;  Surgeon-in-Chief ,  Kensington 
Hospital  for  Womien;  Gynecologist  to  the  Stetson  Hospital;  Consulting  Gynecologist,  Chester 
County  Hospital,  West  Chester,  Pa.;  Consulting  Surgeon,  Philadelphia  Lying-in  Charity, 
Jewish  Hospital  and  Jewish  Maternity  Hospital. 

RICHARD  C.  NORRIS,  A.M.,  M.D Philadelphia,  Pa. 

Assistant  Professor  of  Obstetrics,  University  of  Pennsylvania;  Obstetrician  in  Charge,  Pres- 
ton Retreat;  Gynecologist  to  the  Methodist  and  Philadelphia  Hospitals. 

ALBERT  J.  OCHSNER,  B.S.,  F.R.M  S.,  M.D Chicago,  III. 

Surgeon-in-Chief  of  Augustana  Hospital  and  St.  Mary's  Hospital;  Professor  of  Clinical 
Surgery  in  the  Medical  Department  of  the  University  of  Illinois. 

EUGENE  L.  OPIE,  M.D New  York,  N.  Y. 

Member  of  the  Rockefeller  Institute  for  Medical  Research;  Pathologist  to  the  Presbyterian 
Hospital,  New  York  City. 

J.  F.  W.  ROSS,  M.D Toronto,  Can. 

Professor  of  Gynecology,  University  of  Toronto;  Gynecologist  to  the  Toronto  General 
Hospital. 

STEPHEN  H.  WATTS,  A.M.,  M.D Charlottesville,  Va. 

Professor  of  Surgery,  University  of  Virginia;  Surgeon-in-Chief  to  the  University  of  Virginia 
Hospital. 

J.  WHITRIDGE  WILLIAMS,   A.B.,  M.D.,  S.D Baltimore,  Md. 

Professor  of  Obstetrics,  Johns  Hopkins  University;  Obstetrician-in-Chief,  Johns  Hopkins 
Hospital;  Gynecologist  to  the  Union  Protestant  Infirmary. 


CONTENTS  OF  VOLUME  II. 


CHAPTER  XXVI.  p^^^ 

Complications  Following  Operations 1 

BY  G.  brown  miller,  M.D. 

CHAPTER  XXVH. 

Cesarean  Section  and  Porro-Cesarean    Section 79 

by  j.  f.  w.  ross,  m.d. 

CHAPTER  XXVni. 

Operations  During   Pregnancy 106 

by  richard  c.  norris,  m.d. 

CHAPTER  XXIX. 

The  Operative  Treatment  of  Sepsis  in  the  Child-bearing  Period 117 

by  b.\rt0n  cooke  hirst,  m.d. 

CHAPTER  XXX. 
Extrauterine   Pregnancy 130 

BY  J.  WHITRIDGE  WILLIAMS,  M.D. 

CHAPTER  XXXI. 

Diseases  of  the  Female  Breast ISO 

BY  J.  C.  BLOODGOOD,  M.D. 

CHAPTER  XXXII. 
Operations  upon  the  Gall-bladder,  Bile-ducts,  and  Liver 276 

BY  albert  J.  OCHSNER,  M.D. 

CHAPTER  XXXIII. 

Operations  upon  the  Stomach 318 

by  b.  g.  a.  moynihan,  f.r.c.s. 

Pyloroplasty 374 

BY  J.  M.  F.  FINNEY,  M.D. 

CHAPTER  XXXIV. 
Intestinal  Surgery 383 

BY  JOHN  B.  murphy,  M.D. 

CHAPTER  XXXV. 

Operations  for  Diseases  of  the  Vermiform  Appendix 514 

by  howard  a.  kelly,  m.d.,  and  elizabeth  hurdon,  m.d. 

V 


VI  CONTENTS    OF   VOLUME   II, 

CHAPTER  XXXVI.  p^^e 

Surgery  of  the  Panxreas 557 

by  eugene  l.  opie,  m.d. 

Surgical  Treatment  of  Diseases  of  the  Pancreas 573 

by  stephen  h.  watts,  m.d. 

CHAPTER  XXXVU. 

Operations  upon  the  Spleen 595 

by  howard  a.  kelly,  m.d. 

CHAPTER  XXXVm. 

Tuberculosis  of  the  Peritoneum 617 

by  george  ben  johnston,  m.d. 

CHAPTER  XXXIX. 

Penetrating  Wounds  of  the  Abdomen 639 

BY  FLOYD  W^  McRAE,  M.D. 

CHAPTER  XL. 
Hernia 656 

BY  GUY  L.  HUNNER,  M.D. 

CHAPTER  XLL  '^ 

Operations  for  Inguinal  Hernia  in  ^Ien 696 

by  edward  martin,  m.d. 

CHAPTER  XLII. 

The  Use  of  Drainage  in  Abdominal  and  Pelvic  Surgery 712 

by  brooke  m.  anspach,  m.d. 

CHAPTER  XLIII. 

The  Surgery  of  the  Ureter 732 

by  howard  a.  kelly,  m.d. 

CHAPTER  XLIV. 

Surgery  of  the  Kidney 747 

by  charles  p.  noble,  m.d.,  and  brooke  m.  anspach,  m.d. 


Index ...   841 


Gynecology 

AND 

Abdominal  Surgery. 


CHAPTER  XXVI. 
COMPLICATIONS  FOLLOWING  OPERATIONS. 

By  G.  Brown  Miller,  M.D. 

SHOCK. 

Shock  has  been  defined  by  Gould  as  "the  depression  or  grave  effect  produced 
by  severe  injuries,  operations,  or  strong  emotions;  a  relaxation  or  abolition  of  the 
sustaining  and  controlling  influence  which  the  nervous  system  exercises  over  the 
vital  organic  functions  of  the  body.  It  is  the  result  of  a  profound  impression  made 
on  the  cerebrospinal  axis,  either  directly  through  the  agency  of  an  afferent  nerve, 
or  through  the  circulation."  Some  authors  consider  shock  to  be  a  paralysis  or 
weakening  of  the  vasomotor  center  in  the  medulla,  caused,  reflexly,  by  a  distur- 
bance of  the  sensory  nerves.  As  a  result  of  this  weakening  of  the  center  there  fol- 
lows a  diminution  of  the  tone  of  the  blood-vessels,  a  weakening  of  the  propelling 
force,  and  as  a  consequence  the  blood  tends  to  collect  in  the  veins,  particularly 
those  of  the  abdomen.  There  is  a  lowering  of  arterial  tension  and  probably  an 
anemia  of  the  brain  and  lungs. 

The  causes  of  the  shock  of  operations  are  not  thoroughly  understood.  Pro- 
longed anesthesia  and  exposure  of  the  patient  to  cold,  excessive  loss  of  blood,  and 
much  handling  and  exposure  of  the  abdominal  viscera  seem  to  be  the  chief  causes  of 
shock.  The  condition  of  the  patient  also  plays  an  important  part  in  shock.  The  seat 
of  operation  is  likewise  an  important  factor,  operations  on  the  liver,  gall-bladder, 
and  duodenum  being  most  apt  to  cause  it.  It  is  noticeable  in  extensive  hysterecto- 
mies. The  time  when  shock  occurs  is  usually  during  the  operation  or  within  a 
few  hours  immediately  following  it.  Many  surgeons  think  that  shock  may  come 
on  several  days  after  operation.  This  "delayed  shock"  is  very  rarely,  if  ever, 
seen  following  surgical  operations.  The  symptoms  in  these  cases  are  probably 
due  to  other  things,  such  as  hemorrhage,  sepsis,  tympanites,  embolism,  etc. 

VOL.  II — 1  1 


2  COMPLICATIONS   FOLLOWING    OPERATIONS. 

The  symptoms  of  shock  are  as  follows:  Pallor  and  coolness  of  the  surface 
of  the  body,  which  is  usually  bathed  in  a  cold  perspiration;  the  pulse  is  irregular, 
increased  in  rapidity,  weak  and  thready;  the  respirations  are  irregular,  deep  and 
shallow  breaths  alternating;  the  mind  is  dull  and  apathetic  and  the  special  senses 
are  blunted;  the  face  is  without  expression  and  the  eyes  dull  and  staring,  the  pupils 
are  dilated  and  react  slowly;  the  energy  of  the  muscular  movements  is  diminished; 
there  is  nausea;  the  temperature  falls  1°  to  2°  F.,  and  the  appearance  of  the  pa- 
tient is  that  of  approaching  dissolution. 

Practically  the  only  conditions  with  which  shock  could  be  confounded  are 
secondary  hemorrhage  and  pulmonary  embolism.  A  close  observance  of  the 
symptoms  will  usually  suffice  to  differentiate  between  shock  and  hemorrhage.  A 
knowledge  of  the  operation  and  the  consequent  liability  of  hemorrhage  or  shock  is 
very  important.  A  long  tedious  operation  where  the  intestines  were  much  handled, 
where  the  vessels  were  carefully  ligated,  and  the  oozing  checked  would  make  one 
incline  to  diagnose  shock.  The  detection  of  the  hemorrhage  by  inspection,  pal- 
pation, etc.,  is  of  the  utmost  importance.  Shock  is  usually  seen  before  the  end 
of  the  operation  and  continues  over  the  few  hours  immediately  following;  hemor- 
rhage may  begin  suddenly  at  any  time  within  several  days.  The  pulse  is  different 
in  hemorrhage,  growing  steadily  more  rapid  and  weaker,  and  the  increasing  dysp- 
nea and  restlessness  in  hemorrhage  aid  in  the  diagnosis.  The  blood  examination 
is  of  little  value  in  differentiating  these  conditions  following  operation.  Pulmo- 
nary embolism -occurs  suddenly,  and  frequently  at  a  period  in  the  convalescence 
when  one  would  not  expect  either  shock  or  hemorrhage. 

Following  the  symptoms  usually  seen  in  shock,  one  at  times  sees  extreme 
restlessness  and  almost  maniacal  delirium.  This,  as  a  rule,  quickly  subsides 
and  may  be  again  followed  by  depression  and  by  symptoms  of  collapse.  In  fatal 
cases  the  patients  sink  into  a  stupor  and  the  heart  stops  in  diastole. 

The  treatment  of  shock  consists  in  vigorous  stimulation  of  the  skin  by  rubbing, 
dry  heat,  sinapisms;  the  head  should  be  low.  A  stimulating  enema  of  four  ounces 
of  hot  black  coffee;  or  one  of  eight  ounces  of  salt  solution,  thirty  grains  of  ammo- 
nium carbonate,  and  one  ounce  of  whisky,  should  be  given.  Hypodermic  injections 
of  strychnin  ^^j^  gr.,  repeated  if  necessary  in  two  hours,  are  useful.  Morphin  in 
repeated  small  hypodermic  injections  (gr.  ^  to  ^)  is  one  of  the  best  remedies  we  have, 
especially  where  restlessness  is  present.  If  much  blood  has  been  lost  during  the 
operation,  a  saline  infusion,  500  c.c.  or  more,  under  each  breast  or  into  the  veins  is 
indicated.  Byford  thinks  that  the  application  of  dry  heat  along  the  whole  length 
of  the  patient,  especially  to  the  head,  is  most  important.  Recovery  from  shock  is 
indicated  by  an  improvement  in  the  pulse,  which  becomes  stronger  and  slower, 
the  patient  becomes  warm,  the  respirations  are  deeper  and  more  regular,  the  color 
improves,  and  the  expression  of  the  patient  is  changed  for  the  better.  To  guard 
against  shock  it  is  most  important  to  prepare  the  patient  well  for  the  operation  by 
building  up  her  general  condition,  especially  the  amount  of  hemoglobin  in  anemic 
patients,  thoroughly  emptying  the  intestinal  tract  so  as  to  have  the  intestines  col- 


SECONDARY    HEMORRHAGE.  3 

lapsed  during  operation;  to  shorten  as  much  as  possible  the  length  of  time  of 
anesthesia  and  operation;  to  minimize  the  loss  of  blood;  to  handle  the  intestines 
as  little  as  possible  and  to  protect  them  by  means  of  warm  gauze;  and  to  keep  the 
patient  warm  during  operation.  Olshausen  says  the  use  of  the  Trendelenburg 
position  in  laparotomies  is  justified  on  the  ground  that  it  protects  the  intestines, 
if  for  no  other  reason.  When  symptoms  of  shock  already  exist,  as  in  strangulated 
hernia,  intestinal  obstruction,  etc.,  general  anesthesia  is  contraindicated. 


SECONDARY  HEMORRHAGE. 

Hemorrhage  following  gynecologic  operations  occurs  sufficiently  often  to  make 
its  consideration  important.  In  a  considerable  number  of  the  cases  in  which  it 
occurs  the  hemorrhage  is  not  alarming,  and  frequently  it  is  only  discovered  by 
accident  or  passes  unnoticed.  In  other  cases  only  a  prompt  surgical  interference 
can  save  the  life  of  the  patient,  and  a  few  unfortunates  die  before  any  measures  can 
be  taken  to  check  the  hemorrhage. 

In  7000  operations  in  the  gynecologic  department  of  the  Johns  Hopkins  Hospital 
there  have  been  5  cases  of  serious  hemorrhage  following  laparotomy;  12  cases 
following  perineal  operations;  2  cases  following  vaginal  hysterectomy;  2  cases 
following  trachelorrhaphy;  and  2  cases  after  nephrotomy. 

The  chief  causes  of  secondary  hemorrhage  today  in  gynecology  may  be  stated 
as  follows :  Ligation  or  clamping  of  tissue  en  masse,  cutting  too  close  to  the  ligature 
or  clamp,  the  untying  or  stretching  of  catgut  ligatures,  the  use  of  suture  ligatures, 
the  incomplete  checking  of  capillary  oozing  during  operation,  and  the  loosening 
of  a  thrombus  or  ulceration  of  the  vessel  wall  by  suppurative  processes  following 
operation. 

In  ligating  en  masse  either  the  vessel  may  not  be  sufficiently  compressed  or  the 
tense  tissues  may  offer  so  much  resistance  as  to  cause  the  knot  to  loosen  or  the 
ligature  to  stretch.  It  is  safer  not  to  ligate  a  considerable  mass  of  tissue,  as  the 
pedicle  of  an  ovarian  tumor,  while  it  is  tense.  In  placing  a  ligature  close  to  a  clamp 
which  grasps  a  mass  of  tissue  one  should  remove  the  clamp  at  the  moment  when 
the  ligature  is  drawn  taut.  Large  vessels  should,  if  possible,  be  isolated  before 
being  ligated.  The  stump  of  the  pedicle  should  project  at  least  1  to  1.5  cm.  beyond 
the  ligature.  Whenever  large  vessels  are  ligated  silk  or  kangaroo  tendon  is  to  be 
used  in  preference  to  catgut,  and  when  the  slightest  doubt  exists  as  to  the  safe 
ligature  of  the  vessel  an  additional  tie  should  be  used.  To  prevent  the  untying  of 
catgut  it  is  better  always  to  make  several  ties  in  the  knot.  In  operations  where  su- 
ture ligatures  are  used  to  control  large  vessels,  as  in  nephrotomies,  myomectomies, 
and  perineorrhaphies,  there  is  an  especial  liability  to  post-operative  hemorrhage. 
This  is  noticeably  the  case  in  nephrotomy,  where,  although  the  hemorrhage  appears 
to  be  checked  externally,  it  may  continue  into  the  pelvis  of  the  kidney.  In  a  case 
occurring  in  the  Johns  Hopkins  Hospital  blood-clots  forming  almost  complete  casts 
of  the  dilated  pelvis  of  the  kidney  and  bladder  were  found  at  the  second  operation, 


4  COMPLICATIONS    FOLLOWING    OPERATIONS. 

where  the  kidney  was  removed  to  control  the  hemorrhage.  The  reason  of  this  is 
obvious;  the  vessels  cannot  be  ligated  and  pressure  by  means  of  suture  ligatures 
is  the  only  means  of  checking  the  hemorrhage.  Hemorrhage  is  liable  to  occur  in 
the  repair  of  a  vesicovaginal  fistula  and  the  blood  escape  unnoticed  into  the  bladder. 
At  times,  it  follows  the  too  early  removal  of  the  tampon  or  clamp. 

In  considering  the  time  when  secondary  hemorrhage  is  liable  to  occur  it  is  neces- 
sary to  say  a  few  words  about  the  obliteration  of  ligated  vessels.  This  occurs  either 
by  the  formation  of  a  thrombus,  or  "if  the  ligature  be  applied  aseptically,  and  with- 
out injury  to  the  internal  coats,  usually  no  thrombus  is  formed  or  only  a  small 
one."^ 

In  the  organization  of  a  thrombus  and  the  obliteration  of  the  ligated  vessel  in 
which  no  thrombus  has  formed  the  process  is  an  obliterating  angeitis.  "There 
are  great  diversities  in  individual  cases  as  to  the  rapidity  of  onset  and  the  course 
of  the  organizing  process,  these  differences  depending  upon  various  circumstances, 
the  most  important  of  which  are  the  location  of  the  thrombus,  the  condition  of  the 
wall  of  the  vessel,  the  general  state  of  the  patient,  and  the  presence  or  absence  of 
infection.  In  favorable  cases  the  process  may  be  well  under  way  within  a  week. 
The  presence  of  the  pyogenetic  bacteria  delays  or  prevents  the  process  of  organiza- 
tion." 

The  time  when  we  should  expect  the  hemorrhage  to  occur  in  clean  cases  is, 
therefore,  within  the  first  week.  This  is  really  the  case.  Nearly  all  of  the  secondary 
hemorrhages  occur  within  the  first  forty-eight  hours  following  operation.  In  these 
cases  either  the  hemorrhage  has  not  been  completely  checked  at  the  operation  and 
the  gradual  loss  of  blood  makes  interference  finally  necessary,  or  in  the  violent 
struggles  in  semi-consciousness  and  the  muscular  efforts  made  in  vomiting  when 
the  patient  is  recovering  from  the  effects  of  the  anesthetic  and  the  shock  of  opera- 
tion the  sutures  and  clamps  are  liable  to  slip.  In  cases  where  ordinary  catgut  is 
used  there  seems  a  liability  to  hemorrhage  at  the  end  of  five  or  six  days,  at  which 
time  the  catgut  has  lost  its  strength.  In  post-operative  hemorrhage  due  to  sepsis 
the  bleeding  may  occur  at  any  time,  but  is  usually  after  several  days. 

Symptoms. — The  symptoms  of  secondary  hemorrhage  are  those  of  hemor- 
rhage in  general,  but  may  be,  in  certain  cases,  masked  by  those  of  shock,  sepsis, 
intestinal  obstruction,  and  other  complications.  In  making  a  diagnosis  of  secondary 
hemorrhage  we  are  naturally  influenced  by  the  nature  of  the  operation,  by  the  man- 
ner in  which  the  operator  ligated  the  vessels  and  checked  capillary  oozing,  and  by 
many  other  circumstances  which  common  sense  will  suggest  in  individual  cases. 
The  symptoms  upon  which  we  depend  are  as  follows:  To  be  able  to  detect  the 
loss  of  blood  by  actual  observation  or  by  pelvic  examination ;  continuously  increas- 
ing rapidity  of  pulse-rate  with  a  corresponding  diminution  in  the  volume ;  increasing 
pallor;  quickened,  sighing  respiration,  and,  finally,  marked  dyspnea;  cold,  clammy 
skin  and  extremities;  vertigo;  restlessness;  precordial  distress;  vomiting;  and 
pain  at  the  seat  of  operation. 

»  Welch,  W.  H.:   Allbutt's  "System  of  Med.,"  vi,  165. 


SECONDARY   HEMORRHAGE.  5 

The  blood  examination  is  of  considerable  value  in  some  of  these  cases.  The 
microscopic  examination  of  the  blood  may  not  show  it  to  be  greatly  changed.  All 
of  these  changes  in  the  cellular  elements  are  those  which  are  found  following  an 
operation  where  there  is  considerable  loss  of  blood.  It  aids  in  differentiating  hemor- 
rhage from  sepsis,  pneumonia,  and  those  complications  in  which  one  finds  a  high 
leukocytosis. 

The  typical  picture  of  a  patient  who  is  having  a  secondary  hemorrhage  depends 
upon  the  rapidity  of  the  hemorrhage.  In  those  cases  in  which  a  large  vessel  is  bleed- 
ing the  patient  may  die  in  so  short  a  time  as  to  make  an  observation  of  all  of  the 
above  symptoms  impossible.  In  these  cases  there  will  be  sudden  sharp  pain, 
with  rapidly  increasing  pulse-rate,  extreme  restlessness,  cold  perspiration,  increas- 
ing dyspnea,  and  death.  Kelly^  depicts  a  typical  case  as  follows:  "The  patient 
begins  by  complaining  of  pain  in  the  lower  abdomen ;  her  color  seems  a  trifle  paler 
and  the  pulse  somewhat  quickened.  The  pain  comes  on  in  paroxysms  and  is 
somewhat  diffused.  She  wears  an  anxious  expression  and  she  may  insist  on  seeing 
the  doctor  at  once,  fearful  that  she  is  not  doing  well.  The  radial  pulse  quickly 
becomes  diminished  in  volume,  while  its  rhythm  is  increased  from  twenty  to  thirty 
or  more  beats;  the  legs  and  arms  become  cold  as  the  hemorrhage  continues,  and  the 
radial  pulse  finally  fails  altogether  or  becomes  so  faint  that  it  can  be  detected  with 
difficulty.  The  physician,  arrived  at  the  bedside,  feels  no  pulse  at  all  unless  it  is 
the  pulsation  of  his  own  finger-tips  as  they  are  pressed  deep  into  the  wrist  in  his 
anxiety  to  discover  some  faint  beats.  The  face  assumes  an  ashen  hue,  the  con- 
junctival mucous  membrane  is  no  longer  injected,  the  lips  are  blue,  and  the  gums 
blanched.  A  cold  perspiration  breaks  out  on  the  face  and  the  respiration  is  quick- 
ened and  labored.  The  temperature  is  subnormal.  She  lies  flat  on  her  back 
with  her  chin  elevated  to  make  the  breathing  less  difficult,  and  although  restless 
and  anxious,  remains  motionless  except  an  occasional  tossing  of  the  head  from  side 
to  side  as  the  dyspnea  increases.  She  knows  that  her  condition  is  changed,  but 
often  does  not  appreciate  the  gravity  of  the  situation.  The  accessory  muscles  of 
respiration  come  into  play  toward  the  last  and  she  complains  of  a  painful  or  heavy 
sensation  in  the  cardiac  region.  This  is  apt  to  signalize  heart  failure.  With  the 
increasing  dyspnea  comes  a  sense  of  suffocation  and  a  desire  to  have  the  head 
raised  with  pillows  beneath  the  shoulders.  The  distress  and  half  articulated  gasp- 
ing request  of  the  patient  at  this  time  are  particularly  distressing  to  the  bystander. 
The  heart  impulse  may  still  be  distinctly  felt,  regular  but  sudden,  short,  and 
violent,  over  the  precordium.  Gradually  as  life  ebbs  away  the  pupils  dilate  and 
a  condition  of  apparent  unconsciousness  supervenes,  although  this  state  may  oc- 
casionally be  interrupted  by  a  hurried,  gasping  ejaculation,  showing  that  some 
consciousness  still  remains.  Complete  unconsciousness  gradually  comes  on,  the 
breathing  becomes  short  and  gasping,  the  corners  of  the  mouth  are  drawn  out  in  a 
hideous  grin,  when  at  last,  after  one  or  two  shallow,  gasping  efforts,  respiration 
ceases  altogether.  The  heart  continues  to  beat  some  time  after  respiration  has 
1  Kelly,  H.  A.:  "Operative  Gynecology,"  1898,  ii,  65. 


6  COMPLICATIONS    FOLLOWING    OPERATIONS. 

ceased,  and  after  the  pulsations  are  no  longer  felt  a  slight  tickling  or  faint  con- 
traction, more  or  less  rhythmic,  may  be  detected  for  a  minute  or  more,  and  the 
tragic  scene  is  at  an  end." 

'  If  the  loss  of  blood  is  excessive,  death  results  from  lowering  of  the  arterial 
pressure.  The  amount  of  blood  which  a  patient  can  lose  and  survive  varies  greatly 
with  the  individual  case.  A  sudden  loss  of  three  or  four  pounds  may  cause  death, 
where  if  the  hemorrhage  be  gradual  two  or  three  times  that  amount  may  be  lost 
and  the  patient  live. 

Treatment. — In  sudden  profuse  hemorrhage  practically  nothing  can  be  done,  as 
the  patient  may  die  in  fifteen  to  twenty  minutes.  In  any  case  the  attempt  to  check  the 
hemorrhage  should  be  made  just  as  soon  as  the  diagnosis  is  made.  If  the  hemorrhage 
is  gradual  and  the  diagnosis  is  made  before  the  patient  is  in  too  critical  a  condition, 
she  should  be  taken  to  the  operating  room.  If  absolutely  necessary,  the  operation 
may  be  done  in  the  ward.  Cases  also  in  which  application  of  a  tampon  will  check 
the  hemorrhages  may  be  treated  in  the  ward.  In  operating  in  the  ward  the  want 
of  the  necessary  instruments  and  conveniences,  the  bad  light,  and  the  bad  technic 
make  the  liability  of  sepsis  and  the  want  of  thoroughness  of  the  operation  un- 
avoidable. Having  removed  the  patient  to  the  warm  operating  room  with  as  little 
excitement  and  movement  as  possible,  the  patient  is  placed  on  the  operating  table  and 
the  dressings  removed  before  she  is  anesthetized.  A  hypodermic  injection  of  one- 
sixth  of  a  grain  of  morphin  prior  to  her  removal  from  the  ward  will  do  much 
toward  quieting  the  patient.  The  anesthetic  should  be  begun  while  the  dressings 
are  being  removed,  anesthesia  being  in  most  cases  unavoidable.  While  the  patient 
is  being  anesthetized  the  wound  is  rapidly  sponged  off  with  alcohol,  corrosive  sub- 
limate solution,  and  water.  If  no  suppuration  has  occurred  or  if  it  is  within  forty- 
eight  hours  after  the  primary  operation,  separate  the  adherent  edges  of  the  old 
wound,  removing  the  sutures  as  may  be  convenient.  In  case  of  suppuration  it  is 
better  to  make  another  incision  or  to  cut  out  the  old  wound,  as  the  liability  to  peri- 
tonitis is  increased  by  the  blood  in  the  abdominal  cavity  and  by  the  anemia  of  the 
patient.  Go  at  once  to  the  points  where  the  hemorrhage  is  apt  to  have  occurred, 
isolate  the  bleeding  vessel,  and  ligate  it.  It  is,  at  times,  necessary  to  clamp  the 
point  or  points  of  probable  hemorrhage  until  the  pelvic  cavity  is  so  freed  from  blood 
that  one  can  see  clearly  the  field  of  operation.  In  case  of  nephrotomy  if  the  patient 
is  in  a  critical  condition  and  the  other  kidney  is  acting  well,  it  is  generally  safer  to 
remove  the  kidney.  After  making  sure  that  the  bleeding  vessel  is  tied,  wash  out  the 
blood-clots  with  warm  salt  solution  and  close  the  wound  by  the  most  rapid  method. 
In  cases  of  oozing  it  may  be  necessary  to  tampon.  Occasionally  hemorrhage 
following  plastic  operations  or  nephrotomy  may  be  checked  by  the  pressure  of  a 
tampon,  but  in  the  large  majority  of  cases  it  is  safer  to  open  the  wound  or  at  least 
to  apply  additional  sutures.  Noble  believes  the  hemorrhage  comes  from  the  endo- 
metrium in  most  of  the  cases  which  follow  plastic  operations  on  the  cervix 
or  vagina,  and  finds  tamponing  effectual  in  checking  it.  It  is  the  rule  not  to 
give  saline  infusions,'  stimulants,  etc.,  until  the  bleeding  has  ceased.     However, 


POST-OPERATIVE   VOMITING.  7 

it  is  at  times  necessary  to  give  the  infusion,  etc.,  prior  to  the  operation  on  account 
of  the  weak  condition  of  the  patient.  During  and  after  operation  much  care 
should  be  taken  that  the  patient  be  kept  warm.  Her  hmbs  are  wrapped  loosely 
with  warm  flannel  and  hot-water  bags  are  placed  around  her.  One  should  remember 
the  tendency  of  the  tissues  to  slough  in  these  cases  where  extreme  anemia  exists, 
and  should,  therefore,  be  careful  that  the  hot  bags  do  not  injure  by  coming  in  con- 
tact with  the  patient's  skin.  The  foot  of  the  bed  may  be  elevated  and  hypodermic 
injections  of  brandy,  strychnin,  digitalis,  etc.,  given.  A  stimulating  enema  of 
four  ounces  of  strong  coffee,  along  with  a  saline  infusion  beneath  the  breasts,  is 
very  effectual  in  combating  the  shock  and  immediate  effects  of  secondary  hemor- 
rhage and  of  the  second  operation. 

Following  the  hemorrhage  the  watery  constituents  of  the  blood  are  quickly 
restored  by  absorption  from  the  gastro-intestinal  tract.  The  same  may  be  said 
of  albuminous  elements.  The  hemoglobin  and  the  red  blood-corpuscles  recjuire 
considerable  time  to  reach  the  normal.  In  the  treatment  of  the  anemia  our  chief 
agents  are  good  food  and  fresh  air.  Iron,  arsenic,  strychnin,  the  bitter  tonics, 
etc.,  are  aids.  Blaud's  pills  and  Fowler's  solution — 10  to  15  grains  of  the  former 
t.  i.  d.,  and  three  drops  of  the  latter,  increasing  it  a  few  drops  each  day  until  the 
patient  takes  10  to  15  drops  t.  i.  d. — have  at  times  a  wonderful  effect  in  restoring 
the  red  corpuscles  and  hemoglobin  to  the  normal.  In  a  case  in  the  Johns  Hopkins 
Hospital  where  the  anemia  resulted  from  menorrhagia  due  to  myomata,  the  hemo- 
globin in  three  weeks  was  increased  from  19  per  cent,  to  48  per  cent,  by  means  of 
these  remedies. 

POST-OPERATIVE  VOMITING. 

Nausea  and  vomiting,  more  or  less  pronounced,  follow  nearly  every  operation 
in  which  general  anesthesia  is  employed,  and  also  frequently  accompany  or  follow 
operations  in  which  spinal  or  local  anesthetics  are  used. 

The  causes  of  post-operative  vomiting  may  be  divided  into:  (1)  those  per- 
taining to  the  anesthetic,  (2)  those  pertaining  to  the  stomach  and  intestines,  and 
(3)  those  pertaining  to  the  general  condition  of  the  patient.  The  anesthetic  causes 
vomiting  directly  by  its  irritant  action  on  the  vomiting  center,  and  by  saturating 
the  secretions  of  the  nose  and  throat,  these  being  swallowed  and  thus  irritating  the 
stomach.  Indirectly  it  may  produce  vomiting  by  producing  shock  and  by  its  action 
on  the  kidneys.  The  foregoing  statement  seems  to  be  borne  out  by  the  following 
well-observed  clinical  facts:  i.  e.,  vomiting  which  occurs  frequently  just  before  the 
patient  becomes  profoundly  narcotized  is  doubtless  due  to  its  action  on  the  vomiting 
center;  in  cases  where  there  is  a  great  accumulation  of  mucus  and  saliva  during 
the  anesthesia,  vomiting  is  apt  to  be  excessive;  where  the  patient  is  markedly 
cyanosed,  where  large  quantities  of  the  anesthetic  are  used,  where  shock  is  marked 
or  there  is  partial  or  total  anuria,  vomiting  is  also  liable  to  be  excessive. 

The  causes  pertaining  to  the  stomach  and  bowels  are  chronic  gastric  catarrh, 
dilatation  of  the  stomach,  where  the  stomach  and  the  bowels  have  not  been  emptied 


8  COMPLICATIONS   FOLLO\^^XG   OPERATIONS. 

prior  to  operation,  and  where  there  is  interference  with  normal  peristaUic  action. 
Thus  we  see,  as  a  rule,  marked  vomiting  after  operation  in  patients  upon  whom  emer- 
gency operations  are  performed,  where  there  is  much  handling  and  trauma  of  the 
intestines  during  operation,  in  operations  upon  the  gall-bladder  and  bile-ducts,  or 
where  from  any  cause  there  is  an  obstruction  to  normal  peristalsis  by  reason  of 
local  peritonitis,  drains,  or  adhesions. 

The  causes  pertaining  to  the  general  condition  of  the  patient  relate  to  the  con- 
ditions of  elimination;  to  the  absorption  of  certain  toxic  substances,  such  as  iodo- 
form; to  neuroses;  and  to  idiosyncrasies. 

When  vomiting  is  excessive  and  persistent  it  may  be  a  very  formidable  post- 
operative complication.  It  may  follow  all  attempts  to  swallow  food  or  water  for 
several  days  after  operation.  The  violent  retching  is  very  exhausting  to  the  patient 
and,  at  times,  causes  the  wound  to  burst  open  or  secondary  hemorrhage  to  take 
place.  As  has  been  stated  under  tympanites,  it  is  most  important  to  differentiate 
cases  of  nausea  and  vomiting  unassociated  with  ileus  and  peritonitis  from  those 
where  they  are  symptoms  of  these  affections.  "SMien  vomiting  is  a  symptom  of 
intestinal  obstruction,  one  sees  with  it  tympanites,  intermittent  abdominal  pain, 
intestinal  peristalsis,  inability  to  pass  feces  or  gas  from  the  anus,  an  increasing 
pulse-rate,  and,  finally,  if  the  obstruction  is  complete,  fecal  vomiting.  "When 
associated  with  an  increase  of  pulse-rate,  elevation  of  temperature,  tympanites, 
severe  abdominal  pain,  and  muscle  spasm,  vomiting  usually  indicates  peritonitis. 

Treatment. — Before  formulating  any  method  of  treatment  one  should  en- 
deavor to  ascertain  the  cause  of  the  vomiting.  In  cases  of  ileus  and  peritonitis 
the  treatment  is  directed  toward  the  cause  and  is  given  in  the  sections  on  these 
affections.  If  not  due  to  these  complications  the  treatment  consists  in  giving  the 
stomach  a  complete  rest  for  several  hours,  food  being  given  by  the  rectum,  and 
medicine  and  water  by  the  rectum  and  beneath  the  skin.  Internal  medication  is 
usually  of  little  service,  although  many  drugs  have  been  recommended.  Cocain, 
2  per  cent,  solution  in  ten-minim  doses,  is  perhaps  useful.  Bismuth  subnitrate,  the 
tincture  of  capsicum,  and  other  drugs  are  at  times  given.  A  mustard  plaster  applied 
to  the  epigastrium  until  decided  redness  is  produced  is  useful.  Gastric  lavage  fre- 
quently gives  prompt  relief,  especially  in  cases  where  there  has  been  a  flow  of  bile  into 
the  stomach  or  where  the  stomach  is  much  dilated.  This  is  advocated  by  some  as 
a  routine  procedure  immediately  after  all  prolonged  anesthesias  while  the  patient  is 
unconscious.  It  is  easily  carried  out  and  is  quite  effectual  in  preventing  vomiting. 
One  of  the  chief  indications  is  to  get  a  satisfactory  evacuation  of  the  bowels,  which 
may  be  accomplished  by  means  of  minute  doses  of  calomel  followed  by  enemata,  or, 
in  cases  when  the  stomach  will  tolerate  nothing,  by  enemata  alone.  A  saturated 
solution  of  Epsom  or  Rochelle  salts  (four  ounces)  given  high  (with  the  object  of 
having  it  absorbed),  followed  in  a  few  hours  by  the  usual  enemata,  is  generally 
effective  in  causing  a  free  evacuation.  Enemata  of  a  solution  of  alum  are  verv 
effectual  in  producing  the  same  results.  In  some  cases  in  nervous  women  with 
irritable  stomach  the  ingestion  of  food  will  put  an  end  to  constant  nausea.     If  in 


TYMPANITES.  9 

spite  of  all  treatment  the  vomiting  is  persistent,  especially  when  there  are  eructa- 
tions of  gas,  one  should  suspect  some  form  of  ileus 

Hematemesis  is  occasionally  seen  following  operations  upon  the  abdominal 
viscera.  It  may,  of  course,  be  the  result  of  an  imperfect  application  of  the  sutures 
in  operations  upon  the  stomach  or  small  intestines.  The  causes  of  the  affection 
not  dependent  upon  the  above-mentioned  condition  are  varied,  but  in  considering 
hematemesis  as  a  post-operative  affection,  one  can  usually  regard  it  as  due  to  one 
of  two  conditions:  viz.,  (1)  thrombosis  or  embolism,  and  (2)  toxemia. 

Thrombosis  of  the  omental  vessels,  which  is  generally  produced  by  ligation, 
twisting,  or  injury  of  the  omentum,  may  lead  to  embolism  into  the  stomach  wall. 
Necrosis  with  subsequent  ulceration  ensues,  producing  the  hematemesis.  Throm- 
bosis or  embolism  of  the  mesenteric  vessels,  by  causing  necrosis  of  the  small  intes- 
tines, may  likewise  cause  the  vomiting  of  blood. 

In  cases  of  sepsis,  especially  acute  peritonitis,  and  in  mechanical  ileus,  toxemia 
plays  an  important  role  in  the  production  of  hematemesis.  The  manner  of  its 
production  is  imperfectly  understood.  In  the  majority  of  cases  there  are  no  gross 
lesions  of  the  stomach  or  intestinal  wall,  the  blood  seeming  to  exude  from  the  un- 
broken mucosa. 

The  fact  that  hematemesis  follows  an  operation  should  not  prevent  us  from 
considering  other  causes  of  the  condition,  i.  e.,  those  not  dependent  upon  the  opera- 
tion, as  the  hematemesis  may  accidentally  follow  the  operative  procedure.  These 
causes  may  be  briefly  stated  to  be:  cancer;  ulcer;  aneurism;  varicose  veins;  acute 
congestion,  as  in  gastritis;  passive  congestion  due  to  obstruction  of  the  portal 
circulation,  as  in  cirrhosis  of  the  liver,  thrombosis  of  the  portal  vein,  chronic  disease 
of  the  heart  and  lungs,  disease  of  the  spleen;  the  poisons  of  the  specific  fevers, 
as  smallpox,  measles,  yellow  fever;  poisons  of  unknown  origin,  as  acute  yellow 
atrophy  of  the  liver  and  purpura ;  the  results  of  phosphorus  or  of  corrosive  poisons ; 
certain  constitutional  diseases,  as  hemophilia,  anemia,  cholemia;  or  where  the 
blood  comes  from  the  esophagus,  pharynx,  or  nose  and  is  swallowed.  The  prog- 
nosis depends  upon  the  nature  of  the  lesion  causing  the  condition. 

The  treatment  likewise  depends,  in  part,  upon  the  cause.  Where  this  is  not 
known  or  cannot  be  remedied,  one  has  to  resort  to  the  symptomatic  treatment. 
Lavage  of  the  stomach  with  a  tepid  solution  of  bicarbonate  of  soda,  the  free  evacua- 
tion of  the  bowels,  the  free  use  of  the  normal  salt  solution  subcutaneously,  and 
the  administration  of  a  few  drams  of  water  containing  adrenalin  chlorid,  10  minims 
to  the  dram,  given  every  half  hour,  have  been  recommended. 

TYMPANITES. 
This  condition  arising  after  operation  is  more  frequently  a  symptom  than  a 
complication  itself.  AYhen  marked,  it  usually  indicates  peritonitis  or  some  form 
of  intestinal  obstruction.  Tympanites  is  apt  to  follow  laparotomies  where  the 
bowels  have  been  imperfectly  emptied  before  operation,  and  in  consequence  of 
this  or  some  other  cause  receive  much  handling  and  trauma  during  operation. 


10  COMPLICATIONS   FOLLOWING    OPERATIONS. 

If  the  tympany  is  due  to  ileus  there  is  an  increasing  rapidity  in  pulse-rate,  obsti- 
pation, vomiting,  etc.  With  'peritonitis  these  symptoms  are  usually  accompanied 
by  considerable  fever.     (See  sections  on  ileus  and  peritonitis.) 

The  distended  intestines  pressing  upon  the  diaphragm  interfere  with  respira- 
tion, while  palpitation  and  other  disturbances  in  the  heart's  rhythm  are,  at  times, 
noticed.     The  patient  is,  as  a  rule,  restless  and  uncomfortable. 

The  chief  indication  for  treatment  is  to  cause  peristalsis  of  the  intestines  and 
to  produce  an  evacuation  as  soon  as  possible.  This  is  best  accomplished  by  means 
of  an  enema  of  soapsuds,  glycerin,  and  spirits  of  turpentine,  which  may  be  repeated 
one  or  more  times  if  the  first  trial  is  unsuccessful.  It  is  the  rule  of  many,  and  a 
good  one,  to  give  the  enemata  a  faithful  trial  before  beginning  the  administration 
of  purgatives,  unless  there  is  some  contraindication  to  their  use.  If  the  enemata 
do  not  produce  the  desired  result  small  doses  of  calomel,  Epsom  salts,  or  other 
purgatives,  repeated  at  short  intervals,  should  be  used.  The  passage  of  a  rectal 
tube  is,  at  times,  useful,  and  gastric  lavage,  by  emptying  the  stomach  of  its  gas 
and  other  substances,  tends  to  lessen  the  distention.  Eserin  has  been  highly  recom- 
mended by  some  in  these  cases.  It  can  be  given  hypodermically,  the  salicylate 
being  the  salt  usually  preferred.  Turpentine  stupes  and  the  light  application  of 
the  cautery  to  the  abdominal  walls  frequently  give  considerable  relief  from  pain 
and  probably  encourage  peristalsis.  With  free  evacuation  of  the  bowels,  the 
flatus  escapes;   the  tympany,  as  a  rule,  decreases,  and  finally  disappears. 

One  of  the  most  important  and  frequently  a  most  difficult  question  to  determine 
in  these  cases  is,  whether  the  tympany  is  due  to  an  ileus  or  not.  The  fate  of  the 
patient,  at  times,  hangs  upon  the  surgeon's  timely  decision.  If  after  giving  the 
purgatives  and  enemata  a  faithful  trial,  there  is  no  bowel  movement  and  no  expul- 
sion of  flatus,  it  is  wiser  to  explore.  The  passage  of  flatus  in  any  considerable 
amount  would  indicate  that  the  obstruction  was  at  least  not  complete.  Continued 
nausea  and  vomiting,  intestinal  peristalsis,  obstipation,  and  a  progressive  increase 
in  pulse-rate  usually  indicate  that  the  tympanites  is  a  symptom  of  an  intestinal 
obstruction. 

PECULIARITIES  OF  THE  PULSE. 

Considerable  deviations  from  the  normal  may  exist  in  the  character  and  rate 
of  the  pulse  without  a  known  cause.  Tachycardia  occasionally  arises  after  opera- 
tion, which  is,  so  far  as  we  can  tell,  purely  nervous  in  character,  and  may  give  rise 
to  serious  apprehension  on  the  part  of  the  attendants.  In  one  of  our  cases  the  pulse 
for  several  days  ranged  from  160  to  180,  and  without  any  discoverable  cause.  It 
subsided  rapidly  and  the  patient  had  otherwise  an  uninterrupted  convalescence. 
In  all  cases  where  there  is  a  marked  increase  in  the  pulse-rate  the  patient  should 
be  constantly  watched  and  every  effort  made  to  discover  the  cause.  While,  as  a 
rule,  it  indicates  sepsis,  hemorrhage,  ileus,  phlebitis,  etc.,  there  are  accompanying 
symptoms  in  all  of  these  conditions  which  must  be  present  before  a  diagnosis  can  be 
made.     Any  operative  interference  would  be  unwarranted  upon  this  symptom  alone. 


DIARRHEA.      BED-SORES.  11 

Brachycardia  rarely  follows  gynecologic  operations. 

Intermission  and  other  irregularities  in  pulse  arise  rather  often  after  operation, 
and  their  significance  is  at  times  very  difficult  to  determine. 

As  in  tachycardia,  there  are  generally  other  symptoms  whose  existence  enables 
us  to  make  a  correct  diagnosis  of  the  affection. 

Pericarditis. — As  a  post-operative  complication  pericarditis  is  a  rare  compli- 
cation in  gynecology.  Practically,  it  is  only  seen  in  cases  of  septicemia,  pyemia, 
and  post-operative  pneumonia. 

Endocarditis  may  arise  following  operation,  as  a  result  of  erysipelas,  septice- 
mia, pyemia,  pneumonia  (post-operative),  and  gonorrhea. 

The  symptoms,  diagnosis,  and  treatment  will  not  be  discussed  here. 


DIARRHEA. 

This  condition  is  occasionally  seen  after  operations.  It  is  frequently  a  symptom 
of  uremia  or  of  sepsis.  At  times,  it  is  caused  by  exudates  which  lie  adjacent  to  the 
gut  and  irritate  the  bowel  or  cause  increased  peristalsis.  It  may  be  due  to  an 
inflammation  of  the  bowel  produced  by  local  conditions  or  by  irritating  discharges, 
such  as  pus,  through  a  fistulous  tract.  Some  cases  are  inexplicable.  One  case 
which  I  saw,  followed  the  removal  of  a  large  retroperitoneal  tumor,  and  finally 
caused  the  death  of  the  patient.  Fecal  impaction  and  poisoning  by  drugs,  at  times, 
cause  the  condition.  It  is  not  infrequently  associated  with  an  inflammation  of 
the  pelvic  structures,  kidneys,  bladder,  etc.,  due  to  tuberculosis.  The  lesion  is 
then  a  tuberculosis  of  the  intestine.  Most  cases  are  due  to  an  acute  gastro-enteritis 
caused  by  improper  food,  etc. 

Treatment. — When  the  diarrhea  is  caused  by  sepsis  or  uremia,  no  effort  should 
be  made  to  check  it  unless  the  patient  is  becoming  too  much  exhausted.  In  cases 
of  fecal  impaction,  poisoning  by  drugs,  etc.,  the  removal  of  the  cause  will  generally 
cure  the  condition.  In  most  cases  a  proper  regulation  of  the  diet,  subnitrate  of 
bismuth,  opium,  and  the  usual  remedies  are  indicated.  One  of  the  most  satisfac- 
tory remedies  is  an  enema  of  10  to  40  drops  of  laudanum  in .3  or  4  ounces  of  thin, 
warm  solution  of  starch.  This  will  usually  check  the  movement  and  give  the  pa- 
tient several  hours'  sleep.  In  those  cases  where  an  abscess  opens  into  the  intestine 
nothing  will  effectually  check  the  diarrhea  until  the  suppuration  is  cured. 


BED-SORES. 
In  emaciated  and  weak  patients  unless  great  care  is  exercised  bed-sores  ar€  apt 
to  result.  After  their  formation  they  are,  as  a  rule,  very  troublesome  to  heal,  and 
occasionally  cause  the  death  of  the  patient.  To  prevent  their  occurrence  the  patient 
should  be  turned  frequently  in  bed,  the  bandages  and  dressings  inspected  suffi- 
ciently often  to  keep  them  smooth,  the  utmost  care  exercised  to  keep  the  patients 
clean  and  dry,  and  the  skin  over  the  points  of  greatest  pressure  hardened  by 


12  COMPLICATIONS    FOLLOWING    OPERATIONS. 

frequent  rubbing  with  dilute  alcohol.  Air-cushions  or  pillows  properly  arranged 
are  very  useful  in  preventing  undue  weight  on  the  points  of  greatest  pressure.  After 
the  sores  have  formed  they  should  be  kept  clean  and  dry,  all  pressure  removed 
from  them,  and  they  can  be  dusted  frequently  ^\dth  a  powder  of  iodoform  and  boric 
acid,  calomel,  or  bismuth  subnitrate.  In  intractable  cases  the  continuous  bath 
is  useful  in  promoting  healing. 

OPHTHALMIA. 

The  habit  of  testing  the  conjunctival  reflex  by  touching  the  conjunctiva  with 
the  finger,  as  practised  by  some  anesthetists,  is  responsible  for  many  cases  of  post- 
operative ophthalmia.  Carelessness  in  not  protecting  the  eyes  of  the  unconscious 
patient  from  the  anesthetic,  mucus,  vomitus,  and  other  substances,  likewise  is  the 
cause  of  a  number  of  such  cases.  It  is  quite  conceivable  that  a  gonorrheal  oph- 
thalmia may  be  caused  by  the  finger  of  the  anesthetist  who  has  examined  g^Tiecologic 
cases  shortly  before  the  operation,  and  whose  hands  have  not  been  properly  cleansed 
before  he  administers  the  anesthetic.  The  occurrence  of  the  affection  as  a  post- 
operative disease  usually  means  carelessness  or  ignorance  on  the  part  of  the  assis- 
tant who  administers  the  anesthetic  or  the  nurse  who  has  charge  of  the  patient 
while  she  is  unconscious. 

The  affection  is  usually  mild  and  gets  well  promptly  under  appropriate  treat- 
ment. The  secretion,  when  purulent,  should  be  examined  microscopically  without 
delay,  as  the  preservation  of  the  eye  may  depend  upon  the  discovery  of  the  gono- 
coccus  when  that  microorganism  is  the  cause  of  the  disease. 

The  treatment  in  the  mild  cases  consists  in  frequent  irrigations  of  the  conjunc- 
tiva with  a  boracic  acid  solution,  with  or  without  the  instillation  of  a  weak  astrin- 
gent. For  the  treatment  of  gonorrheal,  diphtheritic,  and  other  grave  forms  of  the 
disease  the  reader  is  referred  to  treatises  on  these  affections. 


PAROTITIS. 

Among  the  complications  which  may  be  met  with  after  operations  upon  the 
abdominal  or  pelvic  organs  is  parotitis.  The  etiology  of  the  affection  is  not  at  all 
well  understood,  the  same  condition  arising,  at  times,  in  diseases  or  derangements 
of  these  organs  when  no  operation  has  taken  place.  In  the  post-operative  cases 
bruising  and  injury  of  the  gland  may  arise  from  forcible  and  ill  directed  efforts  on 
the  part  of  the  anesthetist  to  keep  the  lower  jaw  forward,  and  thus  predispose  to 
inflammation  and  suppuration  of  the  gland.  In  these  cases  the  bacteria  may  gain 
entrance  through  Stenson's  duct  or  through  the  circulation,  the  lowered  resistance 
of  the  gland  enabling  them  to  produce  pathologic  changes.  At  times  parotitis 
appears  to  be  a  part  of  a  septicemia.  Another  theory,  which  has  been  advanced  by 
Dalche,  and  more  recently  by  Dyball,  is  that  the  parotitis  is  due  to  the  action  on 
the  gland  "by  toxic  substances  absorbed  into  the  blood  and  derived  from  (a)  the 
secretions  of  certain  organs  modified  by  injury  or  disease;    (6)  toxins  of  microbic 


ACID    INTOXICATION.  13 

origin  {e.  g.,  bacillus  coli)  absorbed  either  from  the  alimentary  tract,  peritoneal 
cavity,  or  bladder;  (c)  products  of  deranged  digestion."^  Others  believe  that  it  is 
a  sympathetic  inflammation  due  to  reflex  nervous  action,  and  in  support  of  this 
theory  cite  cases  of  orchitis,  etc.,  complicating  mumps. 

The  largest  number  of  cases  seem  to  arise  after  the  removal  of  cystic  ovaries 
and  ovarian  cysts.  In  about  one-third  of  the  cases  the  disease  is  bilateral,  the  pro- 
cess arising  in  one  gland,  and  is  followed  in  twenty-four  to  forty-eight  hours  by 
inflammation  in  the  other  one.  Bonney^  states  that  in  the  greater  number  of  cases 
the  inflammation  subsides  without  suppuration,  but  in  patients  who  are  weak  and 
feeble  the  whole  gland  may  slough.  As  a  rule,  the  affection  does  not  cause  much 
constitutional  disturbance,  there  being  a  slight  rise  of  temperature,  pain,  and  diffi- 
culty in  eating.  In  one  of  Paget's  cases  and  in  a  case  reported  by  Dyball  the  parotid 
affection  seemed  to  be  responsible  for  the  death  of  the  patient.  Where  there  is 
gangrene  and  extensive  suppuration,  the  complication  is  serious. 

The  treatment  consists  of  a  liberal  diet  and  stimulation,  painting  the  skin  over 
the  gland  with  belladonna,  hot  fomentations,  and  if  suppuration  occurs  the  gland 
should  be  freely  incised. 

ACID  INTOXICATION. 

The  importance  of  intoxications  with  acids  that  are  produced  in  the  organism 
in  diabetes  is  generally  recognized.  It  has  been  shown  that  this  condition  of  acid 
intoxication  may  occur  in  such  conditions  as  carcinoma,  grave  anemia,  infectious 
diseases,  and  gastro-intestinal  disturbances.  EdsalF  found  this  condition  present 
in  a  few  cases  of  recurrent  or  cyclic  vomiting  \n  children.  Kelly*  reported  46  cases 
from  the  surgical  wards  of  the  Boston  City  Hospital  where  the  condition  of  aciduria 
or  acetonuria  existed.  In  12  of  the  46  cases  it  was  observed  within  twenty-four 
to  forty-eight  hours  after  the  administration  of  a  general  anesthetic;  in  17  cases 
the  symptoms  were  present  on  their  admission  to  the  hospital ;  and  in  the  remaining 
17  cases  the  condition  developed  after  admission  without  any  assignable  cause. 

The  importance  of  this  condition  of  acetonuria  occurring  after  operation  is 
sufficiently  great  to  call  attention  to  its  chief  symptoms.  These  are  the  peculiar 
pungent  odor  of  acetone  to  the  breath;  apathy;  distaste  for  food;  vomiting;  anil 
the  presence  of  acetone  and  diacetic  acid  in  the  urine.  Little  or  nothing  is  known 
concerning  the  cause  of  the  condition  or  the  relation  which  it  bears  to  surgical  affec- 
tions. The  characteristic  odor  which  it  imparts  to  the  breath  and  the  urinary  tests 
should  make  its  recognition  easy,  and  now  that  attention  has  been  called  to  the 
condition  additional  cases  will  undoubtedly  be  recognized  and  studied. 

'  Dyball,  B.:  "Parotitis  Following  Injury  or  Disease  of  the  Abdominal  and  Pelvic  Viscera," 
Am.  Surg.,  Phila.,  1904,  xl,  No.  6,  886. 

2  Bonney,  W.  F.  V.:  "The  After-treatment  and  Post-operative  Complications  of  Coeliotomy 
for  Pelvic  Disease  in  Women,"  Lancet,  Lond.,  1899,  ii,  337. 

^  Edsall,  D.  L.:  "A  Preliminary  Communication  Concerning  the  Nature  and  Treatment  of 
Recurrent  Vomiting  in  Children,"  Am.  Jour.  Med.  Sci.,  Phila.,  1903,  N.  S.,  cxxv,  629-635. 

^  Kelly,  James  A.:  "Acid  Intoxication;  its  Significance  in  Surgical  Conditions,"  Am.  Surg., 
Phila.,  1905,  xli,  161-200. 


14  COMPLICATIONS   FOLLOWING    OPERATIONS. 

The  treatment  is  largely  symptomatic.  Edsall  advises  in  the  treatment  of 
acetonuria  in  the  cyclic  vomiting  of  children  large  doses  of  sodium  bicarbonate, 
and  believes  it  has  a  markedly  favorable  action.  He  follows  in  this  method  of 
treatment  that  advocated  generally  in  the  treatment  of  the  condition  in  diabetes. 
Kelly  thought  he  obtained  the  best  results  from  the  use  of  adrenalin  chlorid. 
This  was  given  subcutaneously,  500  c.c.  of  a  solution  (1  :  50,000)  being  given  every 
eight  hours. 

LATE  POISONOUS  EFFECTS  OF  ANESTHETICS. 

In  1850  Caspar  called  attention  to  the  poisonous  effects  of  chloroform.  Noth- 
nagel  in  1866  proved  that  chloroform  produced  fatty  degeneration  of  the  liver  and 
heart  muscle  when  injected  subcutaneously  or  when  taken  into  the  stomach.  Num- 
erous writers  have  since  shown  that  chloroform  tends  to  produce  fatty  degeneration 
of  the  liver,  kidneys,  and  heart.  The  subject  has  recently  received  considerable 
attention  in  America,  due  largely  to  a  paper  read  before  the  American  Medical 
Association  by  Bevan  and  Favill,^  in  which  they  call  attention  to  the  action  of 
chloroform  and  ether,  but  especially  the  former,  upon  "the  cells  of  the  liver  and 
kidneys,  and  on  the  muscle  cells  of  the  heart  and  other  muscles,  resulting  in  fatty 
degeneration  and  necrosis,  very  similar  to  the  effects  produced  in  phosphorous 
poisoning."  The  most  important  conclusions  which  they  arrived  at  were  essen- 
tially as  follows :  That  the  liver  is  the  organ  most  often  and  most  seriously  affected, 
and  the  injury  done  to  the  liver  cells  is  in  direct  proportion  to  the  amount  of  the 
anesthetic  employed  and  the  length  of  the  anesthesia;  that  certain  individuals 
exhibit  a  susceptibility  to  the  anesthetic;  that  the  predisposing  causes  to  the  action 
of  chloroform  are  (a)  age,  the  younger  the  more  susceptible;  (6)  causes  which  lower 
the  vitality  of  the  patient,  and  (c)  chronic  diseases  of  the  liver  and  kidneys;  that 
as  a  result  of  the  degeneration  of  the  liver  cells  a  toxemia  is  produced  which  causes 
a  train  of  symptoms  which  consist  of  vomiting,  restlessness,  delirium,  convulsions, 
coma,  Cheyne-Stokes  respirations,  cyanosis,  icterus  in  varying  degrees,  and  that 
death  is  the  usual  termination;  that  acetone  and  diacetic  acid,  and  beta-oxybutyric 
acid  are  found  in  the  blood  and  urine  as  a  result  of  the  toxemia;  that  ether  seldom 
causes  death  in  this  way;  that  chloroform  is  distinctly  contraindicated  in  those 
cases  in  which  there  exist  conditions  which  seem  to  favor  the  development  of  this 
toxemia,  i.  e.,  diabetes,  sepsis,  starvation,  hemorrhage,  the  presence  of  intoxication 
from  dead  material,  the  presence  of  fatty  degeneration  after  infantile  paralysis  and 
lesions  of  the  liver;  that  chloroform  should  not  be  given  to  children  or  in  cases 
where  long  anesthesia  is  necessary. 

A  period  of  ten  to  one  hundred  and  fifty  hours  elapses  between  the  time  of  the 
administration  of  the  anesthetic  and  the  appearance  of  the  symptoms. 

In  Bevan's  case  other  factors  enter  which  could  have  produced  the  toxemia  and 
degen,eration  of  the  liver  and  kidney,  i.  e.,  there  was  a  streptococcic  and  staphylo- 

^  Bevan  (A.  D.)  and  Favill  (H.  B.):  "Acid  Intoxication,  and  Late  Poisonous  Effects  of  Anes- 
thetics; Hepatic  Toxemia;  Acute  Fatty  Degeneration  of  the  Liver  following  Chloroforin  and 
Ether  Anesthesia,"  Jour.  Am.  Med.  Assoc,  Chicago,  1905,  xlv,  691-696. 


SAPREMIA,    SEPTICEMIA,    PYEMIA,    ETC.  15 

coccic  infection  and  an  ovarian  cyst  with  a  twisted  pedicle.  In  most  of  the  reported 
cases  other  factors  have  entered  which  prevent  a  definite  conchision  that  chloroform 
alone  was  responsible  for  the  pathologic  changes  in  the  affected  organs.  However, 
in  view  of  the  facts  obtained  by  experiments  upon  animals  it  is  evident  that  both 
chloroform  and  ether  can  produce  changes  in  organs  essential  to  life,  and  that  we 
should  limit  the  length  of  anesthesia  to  the  shortest  possible  time  consistent  with 
thoroughness  in  operating.  Likewise  the  amount  of  the  anesthetic  and  the  skill 
in  administering  it  are  most  important  factors  in  surgery. 


SAPREMIA,  SEPTICEMIA,  PYEMIA,  ETC. 

During  operations  raw  surfaces  are  formed  and  exposed  to  the  air,  the  hands 
of  the  operator,  sponges,  instruments,  and,  at  times,  to  bacteria  which  are  already 
in  the  tissues.  After  operation,  such  surfaces  are  frequently  left  unprotected ;  blood- 
clots  form  in  spaces  which  have  been  exposed  to  infection;  the  peritoneum  is  ex- 
posed constantly  to  infection  throughout  operations  upon  its  contained  organs ;  and 
sutures  which  pierce  the  skin  are  always  liable  to  be  the  cause  of  suppuration.  In 
view  of  these  facts,  it  is  to  be  expected  that  conditions  of  the  patient  will  frequently 
arise  after  operation  which  are  due  to  the  action  of  bacteria.  The  bacteria  may 
develop  locally  and  only  their  toxic  products  be  absorbed,  or  they  may  enter  the 
blood  and  produce  disease  by  their  presence  as  well  as  by  their  toxins. 

Before  considering  the  conditions  produced  by  bacteria,  it  is  necessary  to  say 
a  few  words  about  aseptic  wound  fever.  In  certain  cases  where  there  is  a  con- 
siderable area  of  raw  surface  formed  during  operation,  oozing  takes  place  afterward, 
the  blood  cannot  escape,  and  the  condition  arises  to  which  the  above  mentioned 
term  has  been  applied.  The  same  condition  exists  in  hemorrhage  into  the  peritoneal 
cavity  after  operation.  The  elevation  of  temperature  which  follows  the  rupture 
of  a  tubal  pregnancy  or  any  intraperitoneal  organ  with  an  outflow  of  blood  is  the 
same  as  aseptic  wound  fever.  The  condition  is  imperfectly  understood,  but  is 
supposed  to  be  due  to  the  absorption  of  some  of  the  products  of  the  blood.  The 
symptoms  are  those  of  a  mild  infection  and  may  subside  in.  a  few  days  without 
treatment.     In  other  cases  it  is  wiser  to  evacuate  the  escaped  blood. 

In  considering  infections  as  post-operative  complications  we  may  conveniently 
divide  them  into  the  following  classes:  Local  infections  with  or  without  marked 
constitutional  symptoms,  sapremia,  erysipelas,  acute  peritonitis,  and  septicemia 
and  pyemia. 

Local  Infections  due  to  Pathogenic  Bacteria. — In  this  class  of  cases  maybe 
placed  stitch  abscesses,  suppuration  of  the  wound,  or  any  localized  infection  where 
only  the  toxins  produced  by  the  bacteria  are  absorbed.  The  bacteria  which  are 
found  most  frequently  in  stitch  abscesses  and  other  local  infections  are  the  staphy- 
lococci. The  Streptococcus  pyogenes,  the  Bacillus  coli  communis,  the  Bacillus 
pyocyaneus  and  others  are  occasionally  found  alone,  or  two  or  more  of  these  bac- 
teria may  occur  in  the  same  inflammatory  process.     The  predisposing  causes  of 


16  COMPLICATIONS   FOLLOWING    OPERATIONS. 

these  infections  are  an  anemic  or  weak  general  condition  of  the  patient,  the  presence 
of  a  blood-clot,  and  constriction  of  tissue  by  means  of  sutures.  A  faulty  technic 
is  usually  responsible  in  clean  cases. 

The  symptoms  are  not  marked  and  generally  make  their  appearance  about  the 
fifth  to  the  eighth  day  after  operation.  There  is  an  elevation  of  temperature, 
usually  not  above  102°  or  103°  F.,  and  slight  general  disturbance  (headache,  ma- 
laise, anorexia,  and  thirst).  The  patient  complains  of  pain  at  the  site  of  the  infec- 
tion, and  upon  examination  one  finds  swelling,  redness,  and  tenderness  at  this 
point,  and  on  pulling  upon  the  suture  or  separating  the  edges  of  the  wound  pus 
makes  its  appearance.  This  is  usually  yellowish-white  and  odorless.  It  is  at 
times  blood-tinged,  and  when  due  to  the  presence  of  the  Bacillus  pyocyaneus  the 
pus  has  a  bluish-green  color.  When  the  Bacillus  coli  communis  or  saprophytic 
bacteria  are  present,  the  odor  is  ofl^ensive. 

The  treatment  consists  in  thoroughly  evacuating  the  abscess  cavity  and  keeping 
it  clean.  The  cleansing  may  be  done  with  boric  acid  solutions,  hydrogen  peroxid, 
a  weak  mercuric  chlorid  solution,  etc.  The  wound  should  be  dressed  once  or  twice 
daily,  a  moist  antiseptic  dressing  hastening  the  healing.  Upon  complete  evacuation 
of  the  cavity  the  symptoms  of  septic  intoxication  rapidly  subside.  The  wound  heals 
by  granulation,  and  this  can,  at  times,  be  hastened  by  approximating  its  edges  with 
adhesive  strips  after  protecting  the  surface  with  gauze,  or  rubber  protective  and 
gauze. 

In  some  cases  where  the  wound  has  been  closed  in  layers  the  skin  surface  may 
have  healed  and  pus  have  formed  in  considerable  quantities  beneath.  In  such 
cases,  when  the  symptoms  of  abscess  arise,  the  skin  should  be  incised  and  the  pus 
evacuated.  Unless  this  is  done  promptly  the  pus  may  burrow  toward  the  perito- 
neal cavity  and  cause  extensive  intestinal  adhesions.  A  few  cases  of  general  periton- 
itis have  been  reported  which  were  caused  by  rupture  of  such  an  abscess  into  the 
peritoneal  cavity.  Extensive  separation  of  the  wound  may  also  result  from  such 
an  accumulation. 

In  hysterectomies  for  myomata,  pelvic  inflammation,  etc.,  where  the  uterus  is 
amputated  supravaginally,  and  in  vaginal  hysterectomies  and  other  operations  upon 
the  uterus  and  vagina,  a  parametritis  or  inflammation  of  the  pelvic  connective  tissue 
may  result.  The  symptoms  are  those  of  other  local  inflammations,  with  frequency 
of  and  pain  on  micturition  and  painful  defecation  superadded.  The  diagnosis  of 
the  affection  can  usually  be  made  by  means  of  vaginal  or  rectal  examination. 

In  cases  of  parametritis  caused  by  the  streptococcus  the  exudate  has  a  bone- 
like consistency  and  frequently  small  abscesses  are  found  scattered  throughout  it. 
The  resulting  exudate  may  go  on  to  abscess  formation  or  may  be  absorbed  without 
any  indication  of  pus. 

The  treatment  of  parametritis  in  the  acute  stages  consists  in  keeping  the  patient 
quiet  and  the  usual  dietary  and  other  general  treatment  of  inflammation.  When 
pus  formation  occurs  or  when  a  definitely  palpable  mass  is  found  on  examination, 
which  can  be  reached  without  exposing  the  patient  to  serious  danger,  it  should  be 


SAPREMIA,    SEPTICEMIA,    PYEMIA,    ETC.  17 

opened  freely  and  drained.  The  incision  may  be  made  through  the  vagina,  above 
the  symphysis,  along  Poupart's  hgament,  or  through  the  perineum,  according  to 
the  situation  of  the  mass.  After  free  incision  and  drainage  the  mass  usually  disap- 
pears in  a  short  time.  In  chronic  cases  the  hot  vaginal  douche,  5  to  8  liters  twice 
a  day,  applications  of  vaginal  tampons  saturated  with  boroglycerid  solution  or  5  to  20 
per  cent,  solution  of  sulpho-ichthyolate  of  ammonium,  and  painting  with  tincture 
of  iodin  are  all  useful.     Pelvic  massage  is  an  aid  to  cure  in  suitable  cases. 

A  similar  condition  occurs  in  retroperitoneal  exudates,  abscesses,  etc.,  which 
may  accompany  or  follow  cases  of  appendicitis.  When  due  to  the  streptococcus 
the  tendency  is  toward  a  lymphangitis  and  not  to  the  formation  of  a  frank  abscess. 

Sapremia. — When  an  extensive  freshly  denuded  surface  is  exposed  and  de- 
composing tissue  is  present,  a  condition  of  the  patient  arises  to  which  the  name 
sapremia  has  been  given.  The  decomposition  is  due  to  the  bacteria  of  putrefaction 
and  the  symptoms  to  the  absorption  of  their  products.  The  symptoms  are  more 
pronounced  in  those  cases  in  which  this  tissue  is  confined  in  cavities  with  a  freshly 
denuded  surface.  Cases  of  this  kind  are  seen  in  puerperal  women  when  a  portion 
of  the  placenta  or  blood-clots  remain  in  the  uterus  and  which  undergoes  putrefac- 
tion, and  they  occasionally  arise  after  gynecologic  operations. 

The  symptoms  begin  suddenly  and  usually  within  a  few  hours  after  the  raw 
surface  has  been  exposed  to  absorption  from  the  decomposing  tissue.  They  may 
arise  within  a  few  hours  after  operation  and  may  not  appear  for  several  days.  The 
temperature  rises  suddenly  to  102°  or  104°  F.  and  is  frequently  accompanied  by  a 
chill.  The  pulse  is  rapid  and  full,  the  face  is  flushed,  and  the  patient  complains  of 
headache,  thirst,  anorexia,  and  occasionally  nausea.  The  respirations  are  more 
rapid,  the  urine  is  scanty  and  high-colored,  and  the  tongue  is  coated.  In  severe 
cases  all  of  these  symptoms  may  be  more  marked,  and  unless  relief  be  afforded 
death  may  take  place  in  a  few  days.  In  other  cases  a  low  typhoid  condition  super- 
venes and  the  patient  finally  dies  of  exhaustion. 

The  prognosis  of  this  condition  following  operation  is  good,  and  rapid  improve- 
ment quickly  follows  the  proper  treatment,  which  consists  in  evacuating  the  cavity 
thoroughly,  irrigating  it,  and  subsequently  keeping  it  clean. 

The  following  was  a  typical  case  of  sapremia:  A  young  woman  who  had  pro- 
duced an  abortion  upon  herself  entered  the  hospital,  complaining  of  an  offensive 
bloody  vaginal  discharge.  Pieces  of  decomposing  placenta  were  found  in  the  vagina 
upon  examination.  She  was  anemic,  had  a  leukocytosis  of  9000,  her  temperature 
was  normal  and  her  general  condition  was  otherwise  good.  The  uterus,  which  was 
large,  soft,  and  retroposed,  was  cureted  in  order  to  remove  pieces  of  adherent 
placenta,  and  on  account  of  free  hemorrhage  was  packed  with  gauze  and  brought 
into  anteflexion.  A  few  light  adhesions  about  the  tubes  and  ovaries  were  broken  up. 
Six  hours  after  the  operation  the  patient's  temperature  was  103.6°  F.,  her  pulse  160, 
and  she  had  a  leukocytosis  of  32,000.  She  complained  of  considerable  pain  in  the 
lower  abdomen.  The  gauze  pack  was  removed,  but  her  condition  remained  un- 
changed during  the  next  few  hours.     On  account  of  the  possibility  of  having  punctured 

VOL.  II — 2 


18  COMPLICATIONS   FOLLOWING    OPERATIONS. 

the  uterus  with  the  curet  or  having  set  free  pus  by  releasing  adhesions,  an  exploratory 
laparotomy  was  done.  Nothing  being  found  to  account  for  her  condition,  the 
uterus  was  thoroughly  irrigated  after  closure  of  the  abdominal  wound.  In  a  few 
hours  she  was  much  better  and  had  no  further  trouble.  Cultures  from  the  uterus 
were  negative.  The  condition  was  evidently  caused  by  absorption  of  the  products 
of  decomposition  by  the  freshly  cureted  surface  of  the  uterus.  Saprophytic  bacteria 
were  undoubtedly  present,  but  did  not  grow  upon  the  culture-media  used. 

Erysipelas. — Erysipelas  of  the  wound  is  sometimes  seen  as  a  post-operative 
complication.  This  is  an  acute  inflammation  of  the  skin  in  the  neighborhood  of 
the  wound  and  is  caused  by  the  Streptococcus  erysipelatos  (Streptococcus  pyogenes). 
The  cocci  are  found  chiefly  in  the  lymph-spaces.  They  may  penetrate  into  the 
tissue  beneath  the  skin  and  get  into  the  general  circulation.  The  cause  is  exposure 
of  the  wound  to  the  streptococcus.  Patients  placed  in  beds  previously  used  by 
cases  infected  with  the  streptococcus,  and  those  whose  wounds  are  dressed  without 
proper  precautions  as  to  asepsis,  are  liable  to  become  infected.  Constitutional 
conditions,  as  alcoholism  and  diabetes,  are  predisposing  causes. 

The  symptoms  are  those  of  localized  inflammation,  to  which  is  added  the  charac- 
teristic appearance  of  the  skin.  There  is  an  itching  or  burning  sensation  in  the 
neighborhood  of  the  wound  and  increased  tenderness.  The  skin  is  swollen,  tense, 
and  red;  small  vesicles  tend  to  form;  and  the  inflammatory  process  shows  a  sharply 
marked  border.  In  case  the  disease  spreads  to  the  deeper  tissues  the  symptoms 
are  more  pronounced.  Abscesses  form  beneath  the  skin,  glands  enlarge  and  suppu- 
rate, and  in  some  cases  the  disease  becomes  a  streptococcic  septicemia  or  pyemia. 

The  treatment  consists  in  applying  antiseptic  solutions  to  the  wound,  bichlorid 
of  mercury,  carbolic  acid,  and  other  similar  remedies  being  used.  In  some  cases 
marked  improvement  has  followed  the  use  of  the  antistrepticoccic  serum.  When 
suppuration  occurs,  free  incision,  thorough  cleansing  of  the  abscess  cavity,  and 
antiseptic  applications  are  necessary.  The  general  treatment  consists  in  good  food, 
stimulants,  etc.  Tincture  of  the  chlorid  of  iron  is  regarded  generally  as  beneficial. 
Isolation  of  the  patient  is  of  the  utmost  importance. 

Peritonitis. — Post-operative  peritonitis  may  be  divided  into  two  forms:  viz., 
local  and  general. 

Local  Peritonitis. — The  causes  of  local  peritonitis  may  be  divided  into  (1) 
mechanical,  (2)  chemical,  and  (3)  bacterial. 

1.  Foreign  bodies,  such  as  aseptic  sponges,  gauze,  instruments,  etc.,  blood-clots, 
pieces  of  tumor  or  other  tissue,  which  have  been  cut  off  from  their  blood-supply 
and  left  in  the  peritoneal  cavity  after  operation,  all  act  as  mechanical  causes  of 
local  peritonitis.  The  adhesions  which  form  as  the  result  of  the  local  peritonitis 
encapsulate  the  body,  which,  if  it  is  sterile  and  is  not  secondarily  infected  from  the 
intestinal  tract,  blood,  etc.,  remains  inert  and  causes  harm  only  by  the  adhesions 
which  have  formed  around  it.  If  infected,  it  produces  either  an  acute  general 
peritonitis  or  a  localized  suppurative  process.     The  latter  generally  occurs. 

2.  When  the  irritating  but  sterile  contents  of  a  cyst  or  degenerated  solid  tumor. 


SAPREMIA,    SEPTICEMIA,    PYEMIA,    ETC.  19 

antiseptic  irrigations,  etc.,  are  set  free  in  the  abdominal  cavity,  a  local  peritonitis 
generally  results,  the  cause  of  which  may  be  regarded  as  chemical  in  its  nature. 

3,  In  the  large  majority  of  cases  where  suppuration  takes  place  in  the  deeper 
layers  of  the  incision,  along  the  stump  of  the  cervix,  etc.,  a  localized  peritonitis 
results,  and  by  the  adhesions  which  form  shuts  off  the  peritoneal  cavity  from  general 
infection.  After  the  removal  of  an  acute  pyosalpinx,  a  suppurating  tumor,  etc.,  a 
localized  peritonitis  may  occur  as  a  result  of  the  local  infection.  These  are  but  a 
few  examples  of  the  many  ways  in  which  bacteria  may  cause  local  peritonitis  fol- 
lowing operation. 

Symptoms. — Pain  at  the  site  of  inflammation  is  an  almost  constant  symptom. 
A  tumor  is  in  some  cases  apparent.  There  is  generally  some  interference  with  the 
natural  movements  of  the  bowel,  and  diarrhea,  or  more  often  constipation,  may  be 
present.  Intestinal  obstruction  is  occasionally  the  result  of  the  adhesions.  Encysted 
fluid  can  in  some  cases  be  made  out.  Fever  is  always  present  when  suppura- 
tion occurs,  and  in  these  cases  the  symptoms  of  septic  intoxication  may  be  more  or 
less  marked.     Distention  is  usually  seen,  but  is  variable  in  amount. 

The  treatment  consists  in  keeping  the  patient  quiet  in  the  early  stages  and  en- 
deavoring to  have  the  process  remain  local.  Opium  is  of  use  here  and  cathartics 
are  contraindicated.  Only  small  quantities  of  liquid,  easily  digestible  food  should 
be  given  by  the  mouth.  The  bowels  can  be  moved  when  necessary  by  means  of 
gentle  laxatives  and  enemata.  If  a  foreign  body  is  the  cause  of  the  disease,  if  sup- 
puration occurs,  or  if  encysted  fluid  is  present,  an  incision  down  to  the  seat  of  the 
trouble,  through  either  the  abdominal  walls  or  the  vagina,  is  indicated.  The 
operator  should  be  careful  to  prevent  infection  of  the  general  cavity  of  the  perito- 
neum. When  the  process  becomes  chronic  the  adhesions  which  have  formed  tend 
gradually  to  stretch  and  separate,  and  may  completely  disappear  in  a  compara- 
tively short  time.  Occasionally  it  becomes  necessary  to  perform  a  secondary  opera- 
tion to  free  the  adhesions.  The  treatment  in  chronic  cases  depends  largely  upon 
the  individual  case  and  consists  in  vaginal  douching,  pelvic  massage,  Swedish 
movements,  general  hygienic  rules,  etc. 

General  Peritonitis. — The  only  form  of  general  peritonitis  which  shall  be  con- 
sidered is  the  acute.  This  is  practically  always  due  to  bacteria.  One  can  conceive 
of  cases  of  acute  general  peritonitis  due  to  chemical  agents,  but  in  practice  they  do 
not  occur.  General  chronic  peritonitis  is  nearly  always  tuberculous  in  character, 
a  few  cases  being  due  to  ovarian  tumors  with  twisted  pedicles,  large  myomata,  etc. 
The  primary  causes  of  the  peritonitis  in  these  cases  are  mechanical  or  chemical, 
the  bacterial  invasion  generally  occurring  after  the  adhesions  have  formed. 

Acute  General  Peritonitis. — Occasionally  there  arises  after  operations  upon  the 
abdominal  organs  an  acute  general  peritonitis. 

Causes. — Pathogenic  or  saprophytic  bacteria  are  found  in  all  cases.  These 
may  be  introduced  during  operation  by  the  hands  of  the  operator  or  his  assistants; 
they  may  come  from  imperfectly  sterilized  instruments,  sutures,  dressings,  etc.; 
they  may  come  from  the  skin  or  genitalia  of  the  patient ;  may  be  present  in  localized 


20  COMPLICATIONS    FOLLOWING    OPERATIONS. 

abscesses  or  suppurating  tumors  and  set  free  during  operation;  may  come  from 
some  lesion  of  the  intestine  either  caused  by  the  operation  or  arising  during  conva- 
lescence; or  may  invade  the  peritoneal  cavity  after  operation  from  suppurating 
wounds,  through  drainage  tracts,  etc.  In  33  cases  of  fatal  post-operative  periton- 
itis reported  by  Flexner,  25  were  mono-infections  and  8  were  mixed  infections. 
The  Staphylococcus  aureus  occurred  twelve  times  alone  and  twice  combined  with 
other  bacteria.  The  streptococcus  was  found  five  times  alone  and  four  times  com- 
bined, and  the  Bacillus  coli  communis  occurred  three  times  alone  and  twice  com- 
bined. The  other  microorganisms  found  were  the  Micrococcus  lanceolatus, 
Staphylococcus  albus.  Bacillus  pyocyaneus,  and  Bacillus  aerogenes  capsulatus. 

It  is  generally  accepted  that  a  general  peritonitis  can  be  caused  by  the  gonococcus. 
This  variety  of  peritonitis  is  usually  seen  prior  to  operation,  but  following  certain 
gynecologic  procedures,  such  as  curetment,  removal  of  adherent  placenta,  etc., 
it  may  also  occur. 

Morbid  Anatomy. — On  opening  the  abdomen  one  finds  the  intestines  injected 
and  distended.  The  amount  and  character  of  the  exudate  are  very  variable.  The 
exudate  may  be  entirely  wanting  and  the  coils  show  only  distention,  slight  injec- 
tion, and  a  loss  of  luster  of  the  peritoneal  surface.  Pawlowsky,  1889,  and 
Fraenkel,  1891,^  proved  by  experiments  on  animals  that  in  certain  cases  of  in- 
fection by  way  of  the  peritoneal  cavity  death  ensued  so  rapidly  that  little  or  no 
inflammatory  reaction  of  the  peritoneum  occurred.  The  exudate  may  be  fibrinous, 
sero-fibrinous,  purulent,  or  hemorrhagic.  In  the  fibrinous  form  there  is  a  deposit 
of  fibrin  on  the  coils,  which  are  more  or  less  glued  together,  with  little  or  no  fluid 
in  the  more  dependent  parts  of  the  peritoneal  cavity.  In  the  sero-fibrinous  form 
there  is  a  deposit  of  fibrin  on  the  coils  of  the  intestine  and  a  large  quantity  of  serous 
fluid  in  the  abdominal  cavity.  In  the  purulent  form  one  finds  pus  in  varying  quan- 
tity, color,  and  odor  in  the  cavity  and  on  the  intestines.  In  several  cases  of  this 
kind  which  I  have  seen  the  infection  had  either  begun  in  the  incision  or  had  extended 
to  it.  The  wound,  especially  along  the  sutures,  was  the  seat  of  suppuration.  In 
the  hemorrhagic  form  the  exudate  is  blood-tinged.  This  is  often  caused  by  the 
oozing  which  follows  the  operation.  It  is  seen  also  in  cases  of  peritonitis  following 
obstruction,  hemorrhagic  infarction  of  the  intestine,  and  in  certain  cases  of  periton- 
itis due  to  saprophytic  bacteria. 

The  character  of  the  exudate  is,  at  times,  changed  by  the  contents  of  the  intes- 
tine, bladder,  etc.,  which  are  occasionally  found  in  the  peritoneal  cavity.  The 
amount  of  the  effusion  varies  from  a  few  hundred  cubic  centimeters  to  several 
liters.  The  exudate  may  partake  of  the  nature  of  several  of  these  forms.  Bumm 
found  in  three  cases  of  infection  from  saprophytic  bacteria  a  foul-smelling,  blood- 
tinged  exudate. 

Symptoms. — The  symptoms  generally  make  their  appearance  gradually  and 
within  twenty-four  to  forty-eight  hours  after  operation.     The  pain  may  be  localized 

^  Cited  by  Engstrom,  O.:  "Ueber  Darmlahmung  nach  operativen  Eingriffen  in  der  Bauch- 
hohle,"  Ztschr.  f.  Geburtsh.  u.  Gynak.,  Stuttg.,  1897,  xxxvi,  399-429. 


SAPREMIA,    SEPTICEMIA,    PYEMIA,    ETC.  21 

in  the  beginning,  but  soon  spreads  over  the  whole  abdomen  and  is  intense.  It  is 
described  as  cutting,  griping,  and  tearing,  and  is  aggravated  by  movements  and 
pressure,  and  consequently  increased  by  talking,  coughing,  etc.  There  is  generally 
great  tenderness  over  the  abdomen  and  the  surface  of  the  skin  is  frequently  hyperes- 
thetic.  The  patient  assumes  the  position  which  relieves  the  tension  of  the  abdom- 
inal walls,  so  that  she  lies  with  the  thighs  drawn  up  and  the  shoulders  elevated. 
On  account  of  the  pain  the  respirations  are  thoracic  in  type.  In  rare  cases  pain 
is  not  a  marked  symptom. 

In  the  beginning  the  abdominal  muscles  are  generally  contracted  and  tense, 
the  abdominal  walls  being  at  times  retracted.  As  the  disease  advances  this  retrac- 
tion decreases  and  the  abdomen  becomes  distended.  The  tympany  is  generally 
excessive,  but  in  a  few  cases  the  abdomen  is  flat  throughout  the  course  of  the  affec- 
tion. 

The  pulse  becomes  very  rapid  early  in  the  disease,  and  this  is  generally  the 
first  indication  of  the  trouble.  It  soon  becomes  small  and  wiry.  The  temperature 
is  variable,  but  is  nearly  always  elevated.  Exceptionally  it  is  but  slightly  above 
the  normal.  It  generally  ranges  between  101°  and  105°  F.,  and  immediately  before 
death  may  reach  108°  to  110°  F. 

Vomiting  occurs  early,  is  usually  persistent,  and  finally  may  be  fecal  in  character. 
It  is  very  exhausting  to  the  patient,  partly  on  account  of  the  severe  pain  which  it 
causes.  The  bowels  may  be  loose  at  first,  but  are  finally  constipated.  Few  cases 
occur  in  which  a  movement  cannot  be  obtained  by  means  of  cathartics  and  enemata. 
The  tongue  is  coated  and  finally  becomes  dry,  red,  and  often  fissured.  Sordes 
appear  on  the  teeth.     There  is  intense  thirst  and  anorexia. 

The  urine  is  scanty  and  high-colored  and  micturition  is  frequent. 

The  respirations  are  hurried  and  shallow  and  hiccough  is  not  uncommon.  As- 
cites is  usually  present  and  is  shown  by  dullness  in  the  flanks  on  percussion.  This 
dullness  may  or  may  not  be  movable,  depending  upon  the  degree  of  intestinal 
adhesions. 

A  leukocytosis  is  always  present,  but  the  number  of  the  count  varies.  The 
value  of  the  sign  as  an  aid  in  diagnosing  this  affection  from  allied  diseases  has  not 
been  settled. 

The  appearance  of  the  patient  is  characteristic.  It  is  that  of  septic  poisoning 
associated  with  pain.  Her  face  is  pinched  and  pale  or  slightly  jaundiced;  her  eyes 
are  sunken  and  staring;  her  cheeks  are  hollow,  and  her  mouth  remains  open.  She 
has  a  wasted  appearance,  is  anxious,  restless,  and  sleepless.  The  intellect  remains, 
as  a  rule,  clear  to  the  last. 

Prognosis. — The  cases  of  acute  septic  general  peritonitis  caused  by  the  Staphy- 
lococcus pyogenes  or  the  Streptococcus  pyogenes  are  almost  uniformly  fatal.  Death 
occurs  in  from  three  to  five  days.  The  prognosis  in  cases  of  infection  coming 
from  the  bowel  or  due  to  saprophytic  bacteria  is  better,  and  that  of  gonorrheal 
peritonitis  is  very  good. 

Diagnosis. — This  depends  upon  the  symptoms  which  have  been  given.     The 


22  COMPLICATIONS   FOLLOWING    OPERATIONS. 

only  post-operative  complication  with  which  it  is  liable  to  be  confounded  is  intes- 
tinal obstruction,  and  the  differences  have  been  set  forth  under  that  heading. 

Treatment. — The  customary  treatment  is  to  reopen  the  abdomen,  evacuate  the 
effusion,  thoroughly  irrigate  the  peritoneal  cavity,  and  drain.  Great  care  should 
be  taken  to  diagnose  a  local  process  from  a  general  peritonitis,  as  in  the  former 
case  the  general  cavity,  of  course,  should  not  be  opened.  In  those  cases  where  the 
cause  of  the  peritonitis  is  an  opening  into  the  intestine,  which  is  frequently  the  case 
after  laparotomies  for  inflammatory  conditions,  this  must  be  sutured.  If  the  pro- 
cess shows  a  tendency  to  confine  itself  to  the  pelvis  or  be  local,  it  is  better  to  cleanse 
by  sponging  and  avoid  contamination  of  the  entire  cavity  by  means  of  irrigation. 
The  drainage  openings  should  be  placed  in  the  most  dependent  parts  of  the  cavity, 
as  the  flanks,  vagina,  etc.  In  reopening  the  abdomen  in  cases  of  general  peritonitis 
one  usually  finds  the  intestines  markedly  distended  and  paretic,  so  that  much  diffi- 
culty is  experienced  in  returning  them  to  the  cavity  when  they  have  once  escaped 
from  it,  or  in  closing  the  abdomen  without  evacuating  their  contents.  Death  is 
hastened  and,  it  may  be,  caused  in  certain  cases  by  the  absorption  from  decompos- 
ing products  of  the  intestinal  contents.  Where  this  marked  distention  exists  it  is 
wiser  to  evacuate  the  gas  and  fecal  material  by  opening  a  loop  of  intestine.  Moyni- 
han^  describes  under  intestinal  obstruction  the  procedure  as  follows:  "The  bowel 
into  which  the  opening  is  to  be  made  is  lightly  clamped  by  an  assistant's  finger, 
and  a  longitudinal  incision,  about  one  inch  in  length,  is  made  in  the  line  opposite 
the  mesenteric  attachment.  The  edges  of  the  wound  so  made  are  lightly  seized 
with  small  vulsellum  forceps  and  are  held  apart,  while  a  glass  tube,  about  six  inches 
in  length,  is  introduced  and  passed  upward  in  the  lumen  of  the  gut.  To  the  outer 
end  of  this  tube  a  long,  thick  rubber  tube  is  attached,  and  this  leads  to  a  receptacle 
beneath  the  table.  The  tube  is  pushed  gently  upward  in  the  distended  gut  until 
its  outer  end  reaches  the  margins  of  the  wound  into  the  bowel.  The  tube  and  gut 
are  then  seized  in  a  wrap  of  sterile  gauze  and  held  firmly  by  the  assistant  so  that  no 
leakage  occurs  by  the  side  of  the  tube.  The  surgeon  then,  with  the  greatest  gentle- 
ness, pulls  the  intestine  on  to  the  tube  and  thereby  empties  the  bowel  a  little  higher 
up.  Gradually  more  and  more  of  the  bowel  is  pulled  onward  until  as  much  of  it 
as  the  tube  will  take  has  been  emptied.  If  the  whole  of  the  distended  gut  cannot 
be  pulled  upon  the  tube,  a  piece  of  the  bowel  at  the  highest  point  which  can  be 
reached  is  seized,  secured  by  an  assistant,  and  'milked'  steadily  downward  by  the 
surgeon."  The  bowel  is  now  closed.  In  the  treatment  of  post-operative  general 
peritonitis  drainage  of  the  intestine  itself  is  thought  by  many  to  be  as  imperative 
as  drainage  of  the  peritoneal  cavity.  This  can  be  effectively  accomplished  by  the 
use  of  the  Paul  or  Mixter  tube.  After  emptying  the  intestine  through  a  transverse 
incision  at  as  low  a  point  as  is  feasible,  a  glass  tube  is  ligated  in  each  end  of  the 
gut,  which  is  brought  outside  the  incision  and  stitched  to  it  in  such  a  way  as  com- 
pletely to  shut  off  the  peritoneal  cavity.  This  artificial  anus  can  be  closed  at 
another  operation  should  the  patient  survive. 

1  Moynihan,  B.  G.  A.:  "Abdominal  Operations,"  1905,  381. 


SAPREMIA,    SEPTICEMIA,    PYEMIA,    ETC.  •  23 

Murphy  claims  such  good  resuks  in  his  treatment  of  diffuse  peritonitis  that  it 
is  well  to  bring  attention  to  his  manner  of  procedure  so  far  as  it  is  applicable 
to  the  post-operative  variety.  It  may  be  briefly  stated  as  follows:  The  elimina- 
tion of  the  cause  of  the  peritonitis  with  the  least  possible  handling  of  the  peritoneal 
contents  and  in  the  shortest  possible  time;  drainage  of  the  pelvis  by  a  suprapubic 
opening;  placing  the  patient  in  the  Fowler  position;  the  absorption  of  large  quanti- 
ties of  saline  solution  through  the  rectum;  and  the  prevention  of  peristaltic  move- 
ments of  the  intestines  by  withholding  all  foods  or  liquids  by  the  mouth  and  the 
administration  of  opium  if  necessary. 

Rest  is  indicated,  and  any  position  which  will  keep  the  patient  most  comfor- 
table may  be  taken.  When  the  infection  has  its  origin  in  the  pelvis  or  lower  abdo- 
men, Fowler's  position  is  indicated.  Little  food  should  be  given  by  the  mouth, 
as  it  excites  vomiting.  Nutrient  enemata  should  be  substituted  largely.  Thirst 
is  relieved  by  enemata  of  the  normal  salt  solution  or  water  400  to  500  c.c.  every 
four  or  five  hours.  Infusions  beneath  the  skin  or  into  a  vein  are  recommended, 
and  are  believed  to  aid  in  the  elimination  of  the  toxins.  Turpentine  stupes  are 
believed  to  lessen  the  pain  and  relieve  distention.  Sponging  with  alcohol  or  tepid 
water  is  refreshing  to  the  patient.  The  mouth  should  be  rinsed  frequently  and 
kept  clean.  In  cases  where  the  bowel  is  not  injured  and  the  process  is  general, 
salines  are  indicated.  Enemata  of  soapsuds  with  turpentine,  milk  of  asafetida, 
and  glycerin  are  aids  in  moving  the  bowels  and  in  the  expulsion  of  flatus.  Strychnin, 
gr.  g-V  to  4V'  every  two  to  four  hours,  should  be  given  hypodermically,  and  morphin 
is  generally  necessary.  In  giving  narcotics  it  is  a  good  plan  to  give  as  little  as 
possible  throughout  the  day  and  give  a  fairly  large  dose  at  night,  so  as  to  give  the 
patient  as  much  sleep  as  possible. 

The  line  of  treatment  varies  with  the  individual  case.  The  principles  outlined 
above  are  applicable  to  those  cases  where  it  is  possible  that  the  infection  comes 
from  the  bowel,  pelvis,  etc.,  and  is  general.  In  the  hope  of  keeping  the  process 
local,  many  advise  giving  opium,  so  as  to  stop  peristalsis  and  allow  adhesions  to 
form.  If  one  could  be  absolutely  certain  of  his  diagnosis,  and  that  the  process  was 
due  to  the  staphylococcus  or  streptococcus,  the  latter  would  be  suitable  treatment. 
Acute  general  peritonitis  following  operation  and  caused  by  either  the  Streptococcus 
pyogenes  or  the  Staphylococcus  aureus  is  perhaps  always  fatal  in  spite  of  all  treat- 
ment. 

Septicemia,  Pyemia. — These  conditions  are  caused  by  the  presence  of  bac- 
teria in  the  circulation.  In  'pyemia  local  abscesses  are  superadded.  They  are 
closely  related  and  are  usually  considered  together.  Both  conditions  as  post- 
operative complications  nearly  always  have  as  their  source  a  local  infection,  although 
the  origin  of  the  infection  may  not  appear  externally.  The  bacteria  which  are 
chiefly  concerned  in  post-operative  septicemia  and  pyemia  are  the  Streptococcus 
pyogenes,  the  Staphylococcus  pyogenes  aureus  and  albus.  Indeed,  the  terms  are 
almost  equivalent  to  such  a  definition,  when  considered  from  a  surgical  standpoint. 
Other  bacteria  have  been  found,  chief  among  which  are  the  Bacillus  anthracis, 


24  COMPLICATIONS    FOLLOWING    OPERATIONS. 

Micrococcus  lanceolatus,  gonococciis,  Bacillus  coli  communis,  and  the  Bacillus 
aerogenes  capsulatus. 

The  bacteria  generally  have  their  portal  of  entry  at  the  site  of  the  operation  or 
wound,  but  they  may  enter  also  at  other  points  and  yet  cause  infections  which 
occur  during  convalescence. 

Septicemia. — The  microorganisms  in  this  condition  multiply  and  generate 
their  toxins  not  only  in  the  wound  but  in  the  blood.  No  characteristic  post-mortem 
appearances  have  been  noted. 

The  symptoms  may  arise  in  a  few  hours  or  within  a  few  days  after  inoculation. 
There  is  generally  a  chill,  which  may  be  repeated  and  severe,  or  only  chilly  sensa- 
tions may  be  felt.  The  temperature  usually  ranges  from  103°  to  105°  F.,  with 
slight  daily  remissions.  The  pulse  is  small,  compressible,  and  rapid,  and  the 
respirations  are  hurried.  Anorexia  is  present,  nausea  and  vomiting  are  usually 
seen,  and  diarrhea  is  at  times  present.  The  patient  is  usually  lethargic.  The 
tongue  is  dry,  with  a  dark  coating  on  the  dorsum  and  with  red  edges;  the  urine  is 
scanty,  high-colored,  generally  albuminous,  and  may  contain  the  infecting  micro- 
organisms. The  skin  is  generally  erythematous  in  the  early  stages  and  later  slightly 
jaundiced,  and  petechial  spots,  scarlatiniform  rashes,  or  herpes  may  appear.  The 
spleen  is  enlarged  and  there  is  a  leukocytosis.  Blood-cultures  usually  show  the 
infecting  bacteria. 

Diagnosis. — The  continuance  of  the  symptoms  after  disinfection  of  local  points 
of  infection  will  diagnose  it  from  local  infections  with  absorption.  Blood-cultures, 
if  positive,  are  diagnostic  of  this  affection  or  pyemia.  The  diagnosis  is  usually 
not  difficult. 

The  'prognosis  is  exceedingly  grave. 

Treatment. — The  wound  should  be  thoroughly  disinfected  or  excised  and  kept 
clean.  The  treatment  otherwise  is  general,  and  consists  in  sustaining  the  patient's 
strength  with  food,  stimulants,  saline  infusions,  strychnin,  etc.  The  temperature 
can  be  controlled  to  a  certain  extent  by  cool  sponging.  In  streptococcic  septice- 
mias the  early  use  of  considerable  quantities  of  antistreptococcic  serum  should  be 
tried. 

Anthrax  infection,  which  occasionally  occurs  after  operation,  from  the  use  of 
imperfectly  sterilized  catgut,  is  very  rare,  and  the  reader  is  referred  to  articles  on 
this  subject  in  a  treatise  on  general  medicine.  Tetanus  may  occur,  but  is  extremely 
rare  after  gynecologic  operations. 

Pyemia. — This  affection  is  bacteremia,  to  which  are  added  abscesses  in  various 
parts  of  the  body.  The  streptococcus  and  the  staphylococci  are  the  bacteria  most 
frequently  found. 

The  mode  of  production  of  the  abscesses  is  usually  given  as  follows:  In  con- 
nection with  a  suppurating  process,  thrombi  form  in  the  vessels;  portions  of  the 
venous  thrombi  become  detached  and  are  carried  through  the  systemic  circulation 
to  the  lungs  or  by  the  portal  circulation  to  the  liver;  these  emboli  lodge  and  produce 
abscesses.     Liver  abscess  seems  particularly  apt  to  follow  appendicitis.     Endo- 


INTESTINAL    OBSTRUCTION.  25 

carditis  is  liable  to  occur,  and  the  infected  emboli  from  the  heart's  valves  form 
abscesses  elsewhere  in  the  body,  as  the  spleen,  the  kidneys,  the  brain,  etc.  Puru- 
lent pleuritis  and  synovitis  are  apt  to  occur. 

Symptoms. — ]More  often  than  in  septicemia  there  are  signs  of  local  infection. 
The  disease  is  generally  ushered  in  with  a  chill  and  a  rapid  elevation  of  tempera- 
ture to  103°  or  104°  F.  This  is  followed  by  profuse  sweating,  and  the  chills  and 
sweating  occur  irregularly  throughout  the  course  of  the  disease.  There  is  anorexia, 
nausea,  and  vomiting.  The  skin  is  at  first  pale  and  is  later  slightly  jaundiced. 
The  spleen  is  enlarged  and  tender.  Lesions  of  the  lungs  occur  and  are  indicated 
by  dyspnea,  cough,  and  local  signs.  Pleurisy  and  pericarditis  are  frequently  present. 
The  patient  develops  a  typhoid  condition  and  becomes  rapidly  emaciated.  AMien 
abscess  of  the  liver  occurs,  icterus  is  usually  present  and  the  liver  is  enlarged  and 
tender. 

Diagnosis. — Blood-cultures  when  positive  are  diagnostic  of  bacteremia.  Ex- 
amination for  Plasmodium  malariee  will  differentiate  it  from  malaria.  Widal's  test 
and  blood-cultures  are  of  great  value  in  differentiating  typhoid  fever  from  the  usual 
forms  of  infection.  Injections  of  tuberculin,  the  history,  and  lung  examination 
will  usually  differentiate  tuberculosis. 

The  prognosis  is  usually  extremely  grave. 

Treatment. — The  same  treatment  should  be  carried  out  as  in  septicemia.  In 
addition,  the  abscesses  which  can  be  reached  should  be  evacuated. 


INTESTINAL  OBSTRUCTION. 

Intestinal  obstruction  is  one  of  the  most  frequent  of  the  serious  complications 
which  follow  operations  upon  the  abdominal  organs.  In  1200  consecutive  cases 
operated  upon  in  the  gynecologic  department  of  the  Johns  Hopkins  Hospital  and 
coming  under  my  personal  observation,  11  were  cases  of  intestinal  obstruction. 
Five  of  these  cases  were  admitted  with  this  condition  existing,  and  in  the  remaining 
6  of  them  the  obstruction  arose  while  the  patients  were  convalescing  from  some 
operation  upon  the  abdominal  organs.  In  this  series  of  1200  cases,  770  were  abdom- 
inal operations.  Thus,  we  had  one  case  of  obstruction  for  each  128  operations 
in  which  the  peritoneal  cavity  was  invaded. 

In  by  far  the  larger  number  of  cases  of  obstruction  following  operation  the  con- 
dition is  caused  by  intestinal  adhesions.  After  simple  operations  upon  clean  cases 
in  which  primary  union  takes  place,  few  or  no  intestinal  adhesions  form,  but  in  a 
very  large  percentage  of  the  cases  where  the  peritoneal  cavity  is  invaded  adhesions 
do  form  which  involve  the  intestines.  These  may  arise:  from  preexisting  adhesions 
which  when  separated  leave  raw  surfaces  that  cannot  be  covered  in  with  peritoneum; 
from  raw  surfaces  left  as  a  result  of  the  operation ;  as  the  result  of  a  local  peritonitis 
which  follows  infection,  mechanical  injury,  hemorrhage,  etc.;  or  as  a  result  of 
infections  which  occur  outside  of  the  peritoneal  cavity  and  by  extending  toward 
it  cause  adhesions.     The  last  condition  is  illustrated  in  suppuration  of  the  abdo- 


26  COMPLICATIONS   FOLLOWING    OPERATIONS. 

minal  wound,  parametritis,  metritis,  suppurative  inflammation  of  the  kidney,  gall- 
bladder, etc.,  where  it  is  owing  to  the  adhesions  of  the  intestines,  omentum,  and 
other  abdominal  organs  over  the  inflamed  area  that  the  general  cavity  is  protected 
from  infection.  When  the  adhesions  are  slight  or  the  gut  fixed  in  a  favorable  posi- 
tion, the  symptoms  of  obstruction  do  not  generally  arise. 

Adhesions  which  follow  operations  may  act  in  a  variety  of  ways  to  cause  obstruc- 
tion.    Treves  makes  the  following  classification: 

(a)  Strangulation  over  a  band. 

(h)  Occlusion  brought  about  by  acute  kinking  due  to  traction  upon  an  isolated 
band  or  an  adherent  diverticulum. 

(c)  Occlusion  effected  by  adhesions  which  retain  the  bowel  in  a  bent  position. 

(d)  Obstruction  by  means  of  adhesions  which  compress  the  gut. 

(e)  Obstruction  by  the  matting  together  of  several  coils  of  intestines. 

(/)    Narrowing  of  the  bowel  from  shrinkage  of  the  mesentery  after  inflammation. 

(a)  Strangulation  over  a  Band  through  an  Aperture,  etc. — (I  do  not 
include  in  this  class  internal  hernise.)  In  these  cases  the  vermiform  appendix, 
Meckel's  diverticulum,  an  epiploic  appendage,  or  a  Fallopian  tube  becomes  adhe- 
rent by  its  extremity,  and  thus  forms  a  band  or  cord  which  can  compress  a  loop 
of  intestine  beneath  it;  or  the  intestine  may  be  snared  or  constricted  by  a  noose  or 
loop  formed  by  the  false  ligament  itself  or  by  slipping  into  an  opening  left  in  the 
omentum  during  operation.  Cases  of  this  class  are  seldom  seen  immediately 
following  operation. 

(6)  Occlusion  brought  about  by  Acute  Kinking  due  to  Traction.— In  these 
cases  a  band  of  adhesions  becomes  attached  to  a  portion  of  the  bowel  and  produces 
an  acute  kinking  and  subsequent  occlusion  by  dragging  upon  this  spot.  Adhesions 
about  the  pylorus,  or  dragging  upon  the  stomach  by  an  omentum  which  is  adherent 
low  in  the  abdominal  cavity,  by  causing  a  sharp  bend  near  the  pylorus  may  cause 
an  obstruction  at  this  point. 

(c)  Occlusion  by  Means  of  Adhesions  which  Retain  the  Bowel  in  a  Bent 
Position. — In  these  cases  the  bowel  may  be  adherent  to  the  pelvic  or  to  the  abdom- 
inal wall,  an  inflamed  tumor  or  exudate,  and  offers  either  a  definite  obstruction  by 
flexion;  or,  by  causing  more  or  less  occlusion  and  resistance  to  peristalsis,  forms  an 
obstacle  to  the  passage  of  the  intestinal  contents.  The  accumulation  of  the  intes- 
tinal contents  above  this  point  tends  to  tighten  the  kink  and  increase  the  obstruction. 
Finally  a  complete  stenosis  occurs  and  the  symptoms  of  obstruction  ensue. 

(d)  Obstruction  by  Means  of  Adhesions  which  Compress  the  Gut.— In 
these  cases  the  intestine  is  adherent  to  the  abdominal  parietes  or  to  the  pelvic  viscera; 
the  adhesions  which  first  form  contract  and  frequently  very  much  lessen  the  caliber 
of  the  gut.  These  forms  of  obstruction  are  usually  found  involving  the  more  fixed 
portions  of  the  intestine. 

(e)  Obstruction  by  Matting  together  Several  Coils  of  Intestines.— This  is 
perhaps  the  most  frec^uent  cause  of  post-operative  obstruction.  The  coils  may  be 
adherent  to  each  other  and  to  the  parietes  or  pelvic  viscera.     The  small  intestine  is 


INTESTINAL    OBSTRUCTION.  27 

usually  involved.  At  times  the  sigmoid  flexure  shows  this  condition,  and  occasion- 
ally the  coils  of  the  large  and  of  the  small  intestine  are  adherent  to  each  other. 

(/)  Narrowing  of  the  Bowel  by  Shrinkage  of  the  Mesentery. — In  cases  where 
there  has  been  extensive  inflammation  involving  the  mesentery,  as  the  scar 
tissue  forms,  a  very  decided  lessening  of  the  intestinal  caliber  is  caused  by  this 
shrinking.     This  class  of  cases  is  seldom  met  with  as  a  result  of  operation. 

Another  form  of  post-operative  obstruction  is  volvulus.  In  this  form  of  ileus 
a  loop  of  bowel  becomes  attached  to  the  abdominal  wall  or  other  structure,  or  the 
two  ends  of  a  loop  of  small  intestine  may  be  drawn  together  by  a  band  of  adhesions 
and  thus  give  rise  to  a  pedicle  about  which  a  volvulus  forms. 

Intussusception  is  perhaps  a  very  rare  cause  of  post-operative  ileus. 

Separation  of  the  incision  and  the  resulting  hernia  is  an  occasional  cause  of 
obstruction ;  and  catching  a  loop  of  gut  with  a  suture  in  closing  the  wound  is  given 
by  Olshausen  as  a  cause. 

Fecal  accumulation  not  due  to  adhesions  following  operation  is  likewise  an 
occasional  cause  of  intestinal  obstruction.  The  accumulation  of  hard  fecal  matter 
in  the  lower  bowel  is  a  not  infrequent  incident  during  convalescence.  It  is  espe- 
cially liable  to  occur  in  those  cases  in  which  an  enema  cannot  be  given,  and  con- 
sequently we  see  it  more  frequently  following  operations  upon  the  rectum,  or  in 
cases  of  complete  tear  of  the  perineum. 

In  the  series  of  the  1200  cases  before  mentioned,  five  entered  the  hospital  with 
an  existing  obstruction.  One  of  these  was  a  strangulated  femoral  hernia;  one,  an 
acute  obstruction  due  to  a  band  of  adhesions;  one,  a  volvulus;  and  the  fifth,  an 
obstruction  due  to  carcinoma.  The  six  cases  originating  in  the  hospital  were  all 
due  to  adhesions.  One  case  was  due  to  a  condition  such  as  described  in  (b),  and 
the  remaining  five  to  a  combination  of  the  conditions  described  in  (c),  (d),  and  (e). 
The  obstruction  was  complete  in  five  of  the  six  cases. 

The  time  of  the  occurrence  of  intestinal  obstruction  with  reference  to  the  opera- 
tion varies  greatly.  It  may  be  months  or  even  years  after  the  operation,  but  as  a 
post-operative  complication  we  are  chiefly  interested  in  those  in  which  the  symp- 
toms arise  during  convalescence  of  the  patient.  The  adhesions  begin  to  form 
immediately,  as  a  rule,  and  hence  the  symptoms  of  obstruction  usually  make  their 
appearance  within  the  first  two  weeks  succeeding  the  operation.  In  the  six  cases 
before  noted,  the  operations  to  relieve  the  post-operative  obstruction  took  place  as 
follows :  Two  upon  the  third,  one  upon  the  sixth,  two  upon  the  eighth,  and  one  upon 
the  twenty-third  day.  In  the  last  mentioned  case  there  was  an  incomplete  ob- 
struction. 

In  noting  the  symptoms  of  obstruction  one  is  struck  with  the  great  difference 
in  their  intensity  in  various  cases.  This  is  explained  by  the  fact  that  it  is  not  so 
much  to  the  occlusion  of  the  lumen  of  the  gut,  as  to  the  injury  to  the  intestine  and 
also  to  the  resulting  invasion  of  the  peritoneal  cavity  by  the  intestinal  bacteria,  that 
many  of  the  more  pronounced  symptoms  are  due. 

As  a  result  of  the  disturbances  of  circulation  there  is  venous  hyperemia,  hemor- 


28  COMPLICATIONS   FOLLOWING   OPERATIONS. 

rhage,  infarct,  edematous  infiltration,  destruction  of  the  epithelium,  and,  in  conse- 
quence, the  possibiHty  of  the  passage  through  the  walls  of  toxic  substances  and 
bacteria.     As  a  result  there  ensues  ulcer  formation,  peritonitis,  etc. 

A  more  important  classification  of  obstructions  for  clinical  purposes  is  the  fol- 
lowing: (1)  Acute  obstruction,  (2)  chronic  obstruction,  and  (3)  acute  obstruc- 
tion supervening  upon  chronic. 

Acute  Obstruction. — The  principal  symptoms  of  acute  obstruction  are  pain, 
vomitings  distention,  collapse,  tenderness,  constipation,  tumor,  and  leukocytosis. 

The  pain  usually  makes  its  appearance  suddenly  and  occurs  in  violent  paroxysms. 
Vomiting  begins  early,  the  vomited  matter  being  at  first  the  contents  of  the  stomach, 
and  later  those  of  the  intestine.  It  may  or  may  not  be  stercoraceous,  depending 
upon  the  seat  of  the  obstruction,  but,  as  a  rule,  finally  it  has  a  distinct  fecal  odor. 
"At  times  there  is  hematemesis,  which  indicates  a  severe  lesion  (hemorrhagic  infarct) 
situated  in  the  small  intestine."^  I  have  noted  this  symptom  in  two  cases  where 
the  obstruction  was  in  the  small  intestine. 

Eructation  of  gas  is  a  valuable  diagnostic  sign.  Distention  begins  shortly  after 
the  onset  of  the  pain  and  vomiting,  and  varies  in  amount  and  location  somewhat, 
depending  upon  the  seat  of  the  lesion.  When  the  seat  of  the  obstruction  is  toward 
the  lower  part  of  the  colon,  the  distention  is  more  marked,  and  is  more  noticeable 
in  the  flanks  than  where  the  small  intestine  is  involved.  Tenderness  is  usually 
present,  being  local  in  the  early  stages  but  later  becoming  general. 

Muscle  spasm  is  generally  present.  Constipation  is  complete.  One  is  some- 
times deceived  by  the  passage  of  flatus  and  fecal  material  in  the  early  stages  from 
the  bowel  below  the  seat  of  obstruction.  Collapse,  marked  in  degree,  is  usually 
present.  This  symptom  is  somewhat  variable  and  cannot  be  depended  upon  to 
indicate  the  condition  of  the  bowel.  Cases  are  seen  which  show  little  depression, 
and  the  condition  of  the  intestine  is  found  at  operation  to  be  such  as  to  exclude  any 
hope  of  recovery.  One  finds,  at  times,  on  physical  examination  a  distinct  tumor. 
The  temperature  is  usually  subnormal.  The  urine  is  usually  diminished  in 
amount  or  may  be  entirely  suppressed,  due  to  an  acute  nephritis,  especially  if  the 
lesion  is  in  the  small  intestine;  it  contains  an  increased  amount  of  indican;  and 
frequently  acetone  and  diacetic  acid.  Increased  peristalsis  and  gurgling  may  be 
seen  especially  early  in  the  disease,  but  it  is  markedly  less  than  in  chronic  cases. 
Local  distention,  according  to  most  observers,  indicates  a  volvulus.  The  greater 
the  pain  and  the  violence  of  the  onset,  the  earlier  the  appearance  of  the  distention 
and  vomiting,  the  more  likely  it  is  that  the  point  of  obstruction  is  in  the  small  in- 
testine.    The  tongue  is  furred  and  the  breath  foul. 

Vaginal  or  rectal  examination  will  at  times  reveal  the  distended  intestine  lying 
in  the  pelvis.  In  one  case  which  came  under  my  observation  an  examiner  mistook 
the  distended  loop  of  intestine  for  an  ovarian  cyst. 

There  may  be  a  leukocytosis.     According  to  Bloodgood,  it  is  usually  over  20,000, 

^  Tietze,  A.:  "Ueber  Hamatemesis  als  Symptom  des  Ileus,"  Deutsche  Ztschr.  f.  Chir.,  Leipz., 
1897,  xlv,  17-23. 


INTESTINAL   OBSTRUCTION.  29 

while  Murphy  states  that  there  is  no  leukocytosis  in  intestinal  obstruction.  This 
sign,  when  present,  is  of  relative  value  only.  So  many  conditions  may  arise  after 
a  laparotomy  which  will  cause  an  increase  in  the  number  of  the  leukocytes  that 
the  sign  is  of  value  only  when  it  is  found  in  conjunction  with  the  other  symptoms 
of  obstruction.  Leukocytosis  is  probably  always  present  in  the  stages  of  acute 
obstruction. 

Chronic  Obstruction. — This  condition,  which  is  the  most  frequent  form  seen 
after  operation,  presents  symptoms  which  differ  considerably  from  those  seen  in 
acute  obstruction.  The  picture  is  usually  the  following  one:  After  an  operation 
in  which  the  abdominal  cavity  has  been  invaded,  one  finds  it  impossible  to  get  the 
patient's  bowels  to  move  properly.  There  are  not  the  free  liquid  movements 
and  expulsion  of  flatus  which  usually  follow  the  customary  purgatives  and  enemata, 
and  finally  complete  constipation  ensues.  The  abdomen  becomes  gradually  dis- 
tended. Nausea,  vomiting,  and  the  regurgitation  of  gas,  which  are  usually 
noticeable  from  the  beginning,  increase  in  persistency  and  intensity.  Visible  peris- 
talsis is  usually  soon  apparent,  and  in  patients  with  thin  abdominal  walls  the  coils 
of  intestines  are  easily  outlined  and  their  forcible  contraction  can  be  felt  and  seen. 
On  auscultation  there  is  gurgling  over  the  point  of  obstruction  when  there  is  partial 
occlusion.  The  pain,  which  is  not  so  marked  as  in  the  acute  cases,  is  more  severe 
with  the  peristaltic  movements  of  the  bowels.  The  pulse  gets  gradually  weaker 
and  more  rapid.  The  temperature  is  not,  as  a  rule,  high,  but  may  be  slightly 
elevated,  as  is  usual  immediately  after  laparotomies.  The  patient  is  restless  and 
suffers  from  thirst.  Collapse  is  not  so  marked  as  in  acute  cases,  but  if  interference 
is  delayed  the  patient  soon  becomes  weak.  The  urine  may  be  diminished  or  com- 
pletely suppressed.  The  tongue  is  furred  and  the  breath  foul.  In  man}-  cases 
the  symptoms  of  obstruction  are  not  at  all  marked  immediately  after  operation, 
and  all  that  one  notices  is  a  difficulty  in  moving  the  patient's  bowels,  slightly  more 
pain  than  is  usual  in  such  cases,  and  some  distention.  As  the  adhesions  become 
denser  and  contract  the  symptoms  become  more  marked,  and  finally  all  of  the 
symptoms  of  obstruction  are  present.  Again,  at  first  the  symptoms  of  chronic 
obstruction  ensue  when  by  a  kink  in  the  intestine  or  accumulation  of  fecal  material 
the  occlusion  is  suddenly  brought  about. 

In  cases  of  fecal  accumulation  the  symptoms  are  all  less  marked.  In  these 
cases  there  is  griping  pain  and  the  general  symptoms  of  chronic  obstruction.  When 
the  accumulation  is  situated  in  the  rectum,  there  is  a  feeling  of  distention  and  a 
desire  to  defecate  which  is  not  relieved  by  the  liquid  movements  caused  by  purga- 
tives. In  those  cases  where  the  mass  is  situated  in  the  true  abdominal  cavity  a 
tumor  is  apparent  until  disguised  by  the  distention.  Where  the  impaction  is  low, 
a  digital  examination  will  reveal  the  nature  of  the  condition.  After  operation  when 
a  feeling  of  fullness,  etc.,  in  the  rectum  is  complained  of  by  the  patient,  a  digital 
examination  should  be  made. 

Diagnosis. — It  is  to  be  desired,  but  not  usually  necessary,  to  make  a  diagnosis 
of  the  form  or  the  cause  of  the  obstruction.     The  treatment  is  the  same,  and  it  is,  as 


30  COMPLICATIONS    FOLLOWING    OPERATIONS. 

a  rule,  impossible  to  tell  the  nature  of  the  obstruction  until  the  abdomen  is  reopened. 
Practically  the  only  condition  which  is  liable  to  be  confounded  with  post-operative 
obstruction  is  acute  peritonitis,  and  in  both  the  treatment  is  an  exploratory  lapar- 
otomy. The  distinguishing  differences  are  usually  the  following:  In  peritonitis 
the  temperature,  as  a  rule,  is  higher,  there  is  usually  no  visible  peristalsis,  and  at 
first  there  is  contraction  of  the  abdomen,  and  finally  a  more  general  distention,  there 
is  less  nausea  and  vomiting,  the  obstipation  is  not  so  complete,  the  leukocytosis  is 
higher,  the  tongue  is  drier  and  redder,  and  there  is  more  general  tenderness,  and 
more  marked  muscle  spasm.  In  many  cases  of  peritonitis  the  effusion  into  the 
peritoneal  cavity  is  of  extreme  value  in  distinguishing  this  affection  from  obstruction. 

The  prognosis  in  any  case  is  grave  and  depends  largely  upon  the  time  when 
operative  interference  takes  place.  There  are  few  surgical  diseases  which  call 
more  imperatively  for  an  early  operation  than  mechanic  intestinal  obstruction.  If 
a  certain  stage  is  passed  the  mere  relief  of  the  obstruction  does  not  save  life.  The 
prognosis  is  better  in  the  chronic  than  in  the  acute  cases.  Of  the  eleven  cases  which 
have  been  cited,  and  all  of  whom  were  operated  upon,  seven  died  of  the  affection, 
one  who  had  typhoid  fever  as  a  complication  likewise  died,  and  only  three  recovered. 
The  cases  which  terminated  favorably  were  post-operative  in  character  and  an 
early  diagnosis  undoubtedly  saved  their  lives.  Treves  states  that  the  mortality 
of  the  operation  for  acute  obstruction  is  about  75  per  cent.,  Richardson  reports 
six  cases  of  acute  obstruction  due  to  adhesions  and  bands  with  a  mortality  of  50 
per  cent.,  while  the  mortality  in  our  cases  (post-operative),  after  ruling  out  the 
typhoid  fever  case,  was  40  per  cent.,  and,  counting  it,  50  per  cent.  All  of  the 
women  who  entered  with  obstruction  died;  indeed,  all  were  in  extremis  when 
operated  upon. 

Treatment. — The  prophylactic  treatment  is  most  important.  The  surgeon 
should  in  abdominal  cases  handle  the  intestines  as  little  and  as  gently  as  possible. 
Injury  to  the  abdominal  wall  by  means  of  retractors  should  be  avoided.  Raw 
surfaces  should  be  covered  over  with  peritoneum.  Extreme  care  must  be  used  in 
closing  the  abdominal  wound,  the  peritoneal  surfaces  being  accurately  adapted. 
Skilful  adjustment  of  the  omentum  so  as  to  cover  in  raw  surfaces  is  of  much  value. 
The  intestines  should  be  arranged  as  nearly  as  possible  in  a  normal  position,  and 
some,  following  the  example  of  Clark,  fill  the  abdominal  cavity  with  normal  salt 
solution  after  operations  to  allow  the  intestines  to  adjust  themselves  properly  and 
thus  prevent  obstruction,  even  though  adhesions  do  form.  The  early  moving  of 
the  bowels  likewise  tends  to  prevent  obstruction. 

After  the  diagnosis  has  been  made,  no  time  should  be  lost  in  attempting 
to  relieve  the  condition.  Following  vaginal  hysterectomy,  it  is  the  custom  of 
some  in  cases  where  the  symptoms  arise  in  the  first  few  days  after  operation,  to 
attempt  to  separate  the  adhesion  through  the  vagina.  It  is  better  in  any  case  to  do 
an  exploratory  laparotomy.  It  is  a  good  practice,  when  in  doubt,  to  explore.  The 
inexperienced  are  almost  certain  to  err  on  the  other  side  and  to  wait  so  long  that 
the  patient  dies  in  spite  of  the  relief  of  the  obstruction.     Opium  may  be  given  after 


INTESTINAL   OBSTRUCTION.  31 

the  diagnosis  is  made,  and  warmth  and  other  measures  to  reheve  the  collapse  are 
to  be  recommended  while  preparing  for  operation.  Infusion  of  salt  solution  is  very 
useful  in  these  cases.  In  making  the  second  incision  the  same  rules  hold  good  as 
given  in  hemorrhage.  Go  at  once  to  the  seat  of  operation,  examining  carefully  also 
whether  the  intestines  are  adherent  to  the  abdominal  wound.  If  the  point  of  obstruc- 
tion cannot  readily  be  found,  it  is  a  good  plan  to  examine  first  the  cecum  and  see 
if  the  distention  has  extended  to  this;  if  not,  follow  the  small  intestine  back  until 
it  is  reached.  If  the  obstruction  occurs  below  the  cecum  and  the  operation  has 
been  upon  the  pelvic  organs,  go  to  the  sigmoid,  as  this  is  the  probable  point  of 
obstruction.  In  some  cases  it  is  necessary  to  eviscerate  the  patient,  but  it  is  better 
to  avoid  this  if  possible,  and  when  necessary  the  intestines  must  be  covered  with 
warm  moist  gauze.  Having  found  the  point  or  points  of  obstruction,  the  adhe- 
sions should  be  carefully  separated  and  the  condition  of  the  gut  examined.  Where 
the  gut  is  gangrenous  one  of  two  things  remains  to  be  done:  one  can  either  resect 
the  gangrenous  intestine,  or  bring  this  portion  outside  the  abdominal  cavity  and 
make  an  artificial  anus.  The  gangrenous  gut  in  the  latter  case  should  be  stitched 
to  the  skin  if  there  is  any  difficulty  in  keeping  it  outside,  and  opened  as  soon  as 
adhesions  have  shut  off  the  peritoneal  cavity.  The  immediate  emptying  of  the 
intestinal  contents  is,  at  times,  most  important.  In  cases  of  great  distention,  even 
where  the  intestine  is  not  gangrenous,  the  gut  should  be  freely  opened  and  the  con- 
tents of  the  intestine  allowed  to  escape.  This  should  be  done  by  bringing  a  loop 
of  the  intestine  well  outside  the  abdominal  cavity,  a  transverse  incision  should  be 
made,  and  the  intestinal  contents  forced  out.  The  use  of  the  glass  tube,  as  described 
under  Peritonitis,  facilitates  this  procedure.  The  emptying  of  the  bowel  by  this 
means  serves  several  purposes;  it  allows  the  decomposing,  poisonous  contents  to 
escape,  it  relieves  the  disturbances  of  circulation,  it  allows  the  intestines  to  be  re- 
placed more  easily  after  operation  is  over  and  alleviates  the  discomfort  of  the  patient. 
Great  care  should  be  exercised  in  protecting  the  peritoneal  cavity  from  infection 
and  in  closing  the  opening  in  the  gut.  Puncture  with  an  aspirating  needle  is  useless. 
In  some  cases  where  there  is  no  gangrene  it  may  be  necessary  to  resect  the  gut. 
After  the  adhesions  have  been  separated  and  it  is  certain  that  the  obstruction  is 
overcome,  the  intestines  are  carefully  arranged  and  the  abdomen  closed  either  with 
or  without  drainage,  according  to  general  surgical  principles.  When  the  cause  of 
the  obstruction  is  a  fecal  accumulation  the  treatment  consists  in  trying  to  move 
the  mass  along  by  gentle  manipulation,  enemata,  and  purgatives:  If  it  is  situated 
in  the  rectum  it  should  be  removed  manually,  if  necessary,  after  softening  it  by 
means  of  olive  oil  and  soapsuds  enemata.  Great  care  should  be  taken  not  to 
break  down  the  wound  of  the  rectum  or  perineum.  In  case  manipulations,  etc., 
fail  to  relieve  the  high  fecal  accumulation,  it  should  be  removed  by  means  of  a 
laparotomy. 

Two  interesting  forms  of  ileus  have  been  observed  which  do  not  depend  upon  a 
mechanical  obstruction,  but  which  seem  due  to  some  abnormality  in  the  nervous 
mechanism  of  the  bowels. 


32  COMPLICATIONS   FOLLOWING    OPERATIONS. 

Paralytic  Ileus. — (Ileus  paralitique  of  the  French.) — Olshausen^  in  1887  first 
reported  cases  of  this  form  of  post-operative  ileus,  and  since  his  report  numerous 
cases  have  come  to  light.  In  this  form  of  ileus,  without  a  definitely  known  cause 
the  bowel  becomes  distended  and  to  all  appearances  paralyzed.  Frequently  follow- 
ing laparotomies  we  see  distention,  which  disappears  as  soon  as  the  bowels  move, 
but  in  cases  of  paralytic  ileus  the  distention  increases  and  complete  constipation 
ensues. 

The  causes  of  the  condition  are  not  known.  It  is  regarded  as  total  or  partial 
paralysis  of  the  intestines.  Prolonged  handling  and  eventration  of  the  intestines, 
trauma,  injuries  of  the  nerves  of  the  mesentery,  and  increased  intra-abdominal 
pressure,  such  as  sometimes  occurs  after  operations  for  large  umbilical  hernia  in 
fat  individuals,  are  etiologic  factors.  In  some  of  the  reported  cases  the  so-called 
ileus  was  probably  a  rapidly  fatal  peritonitis,  but  a  sufficient  number  of  authentic 
cases  exist  to  cause  this  affection  to  be  considered  as  a  distinct  variety  of  ileus.  In 
other  cases  toxemia  from  contaminated  or  decomposing  food  appears  to  be  the 
cause  of  the  condition. 

The  symptoms  usually  come  on  in  two  or  three  days,  although  most  of  the  patients 
seem  to  do  badly  almost  immediately  after  operation.  The  patients  are  usually 
extremely  nervous  women.  The  symptoms  are  distention,  vomiting  which  finally 
becomes  fecal,  complete  constipation,  increasing  rapidity  of  pulse,  and  the  signs  of 
collapse.  The  distention  seems  to  be  less  marked  than  is  the  case  in  mechanical 
obstruction,  and  intestinal  peristalsis  is  wanting.  The  temperature  is  usually 
subnormal.  The  urine  may  be  scanty  and  have  an  increased  amount  of  indican. 
In  fatal  cases  the  patient  probably  dies  of  septic  intoxication  from  absorption  of  the 
products  of  the  decomposition  of  the  intestinal  contents. 

The  treatment  has  not  been  definitely  formulated.  The  immediate  emptying 
of  the  intestinal  canal  by  the  formation  of  an  artificial  anus  ofl^ers  the  best  hope  of 
recovery.  In  the  early  stages,  strychnin,  the  faradic  current,  massage,  the  light 
application  of  the  cautery  to  the  abdomen,  and  enemata  are  recommended.  Vogel, 
Ardt,  Craig,  and  others  highly  recommend  hypodermic  injections  of  eserin.  It 
seems,  however,  to  be  of  doubtful  value  according  to  other  observers. 

Spastic  Ileus  (the  So-called  Dynamic  Ileus). — Several  cases  have  been 
reported  since  1897  of  a  post-operative  spasmodic  contraction  of  the  bowel  giving 
rise  to  the  symptoms  of  obstruction.  In  these  cases  the  condition  occurred 
subsequent  to  operation  upon  some  of  the  abdominal  or  pelvic  viscera.  In  one 
of  them^  the  patient  had  practically  all  of  the  symptoms  of  intestinal  obstruc- 
tion, the  case  was  diagnosed  as  such,  and  a  second  operation  was  performed  to 
relieve  the  obstruction.  At  this  operation  ten  inches  of  the  ileum  situated  just 
above  the  ileocecal  valve  was  found  tightly  contracted  and  completely  occluding  the 
lumen  of  the  gut.     Nothing  could  be  found  to  account  for  the  contraction  and 

^  Olshausen:  "Ueber  eine  bisherunerkannteTodesursachenach  Laparotomien  mit  eventration 
der  Darmschlingen,"  Ztschr.  f.  Geburtsh.  u.  Gynak.,  Leipz.,  1888,  xii,  238-241. 

^  Blume,  F.:  "Dynamic  Ileus  Following  Operations  Involving  the  Abdominal  Cavity,  with 
Remarks  on  Adynamic  Ileus,"  Am.  Jour.  Obst.,  N.  Y.,  1897,  xxxvi,  584-586. 


ACUTE   DILATATION    OF   THE    STOMACH.  33 

nothing  abnormal  was  noted  except  slight  abrasion  of  the  peritoneal  coat  in  one 
place.  The  bowel  above  the  contraction  was  distended;  that  below,  collapsed  and 
soft.  There  were  no  signs  of  peritonitis  or  any  other  lesion  to  account  for  the  symp- 
toms. An  artificial  anus  was  made  and  the  patient  died  several  hours  afterward. 
This  is  apparently  a  case  of  death  following  operation,  due  to  spasmodic  ileus. 
In  another  reported  case  the  tightly  contracted  condition  of  the  gut  was  found  at 
autopsy  and  the  symptoms  were  not  those  of  obstruction  but  of  toxemia.  In  other 
cases  occurring  after  operation  intestinal  adhesions  existed,  and  the  obstruction 
may  have  been  due  to  these,  although  they  were  not  deemed  by  the  operators  to  be 
the  cause  of  the  ileus.  Kocher^  says  that  in  most  cases  of  so-called  dynamic  ileus 
(meaning  both  forms)  the  condition  is  by  no  means  a  pure  functional  disturbance, 
but  that  there  are  light  mechanical  hindrances  which  lie  in  the  background. 

The  length  of  the  contracted  portion  of  the  intestine  varied  from  a  few  centi- 
meters to  that  of  the  entire  large  intestine.  The  situation  can  apparently  be  in  any 
part  of  the  intestine.  In  several  reported  cases  of  spastic  ileus  where  the  primary 
operation  was  performed  for  a  supposed  intestinal  obstruction  the  contracted  gut 
was  seen  to  dilate  while  under  observation.  In  one  of  these  cases  lead  poisoning 
was  considered  the  cause  of  the  spastic  condition  of  the  bowel.  A  similar  condi- 
tion probably  exists  in  the  well-known  condition  of  hysterical  tympanites.  Mur- 
phy^ thinks  that  poisoning  by  tyrotoxicon  can  cause  it,  and  a  case  of  Werder's  tends 
to  show  this  theory  to  be  correct.  Israel  reports  a  case  where  a  comparatively 
small  gall-stone  (2  cm.  in  diameter)  caused  a  spasmodic  contraction  of  the  bowel 
and  a  complete  obstruction. 

The  condition  is  a  very  interesting  one,  and  further  observations  upon  it  are 
desirable. 

The  treatment  theoretically  would  be  to  employ  remedies  to  relax  the  spasm, 
such  as  atropin,  morphin,  the  hot  bath,  etc.  In  some  cases  it  may  become  neces- 
sary to  make  an  artificial  anus.  An  exploratory  laparotomy  is  indicated  if  other 
remedies  are  not  effectual,  and  should  be  done  before  the  patient  becomes  very 
weak.  A  positive  diagnosis  can  be  made  only  by  means  of  it,  and  adhesions  or 
other  observed  causes  of  the  condition  may  be  removed. 


ACUTE  DILATATION  OF  THE  STOMACH. 

A  few  cases  of  acute  dilatation  of  the  stomach  have  been  observed  following 
operation  or  the  administration  of  a  general  anesthetic.  Attention  has  recently 
been  directed  toward  the  condition,  and  it  is  probable  that  many  additional  cases 
will  be  added  to  the  few  already  reported.  Two  varieties  have  been  noted:  (1)  a 
paralytic  condition  of  the  organ,  which  becomes  tremendously  dilated,  producing  a 
constriction  by  its  weight  at  the  pylorus,  and  (2)  an  interesting  form,  called  "gastro- 
mesenteric  ileus,"  in  which  there  is  a  compression  of  the  duodenum  where   it 

^  Kocher:  "Ueber  Ileus,"  Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  Jena,  1898,  iv,  195-230. 
2  Murphy,  J.  B.:   "Ileus,"  Deutsche  Ztsehr.  f.  Chir.,  Leipz.,  1897,  xlv,  506-530. 

VOL.  II — 3 


34  COMPLICATIONS   FOLLOWING    OPERATIONS. 

passes  beneath  the  superior  mesenteric  vessels,  causing  a  dilatation  of  the  stomach 
and  duodenum  above  the  constriction. 

The  etiology  of  the  condition  is  obscure.  The  first  variety  is  supposed  by 
some  to  be  a  paralytic  distention.  Adhesions  of  the  omentum  to  the  seat  of  the 
pelvic  operation,  or  to  the  abdominal  incision,  by  dragging  the  stomach  down  tend 
to  cause  a  stenosis  at  the  pylorus  or  gall-bladder,  or  a  partial  stenosis  of  the  pylorus 
may  be  produced  by  adhesions,  tampons,  drainage-tubes,  etc.,  the  subsequent  dila- 
tation of  the  stomach  tending  to  perpetuate  the  condition.  Cases  in  which  there 
exists  at  the  time  of  operation  an  enteroptosis,  a  chronic  dilatation  of  the  stomach, 
or  chronic  gastritis  seem  more  prone  to  the  affection. 

In  the  second  variety  there  seems  to  be  a  definite  constriction  of  the  duodenum 
at  the  point  where  it  passes  beneath  the  mesenteric  vessels.  It  is  apparently  com- 
pressed between  these  vessels  and  the  vertebree.  The  cause  of  this  variety  is  like- 
wise very  obscure.  The  theory  is  that  the  small  intestines  from  some  cause  drag 
so  upon  the  mesentery  that  the  vessels  are  made  tense  and  thus  constrict  the  duo- 
denum. A  dilated  stomach  filled  with  fluid  and  gas  tends  to  push  the  intestines 
downward  and  in  tins  manner  cause  the  constriction.  Hence  it  would  seem  that 
dilatation  of  the  stomach  and  gastro-mesenteric  ileus  are  very  closely  related.  Dila- 
tation of  the  stomach  can  apparently  cause  constriction  by  the  mesenteric  vessels 
and  vice  versa.  Adhesions  of  the  great  omentum  causing  a  dilatation  of  the  sto- 
mach, or  of  the  small  intestines  to  the  pelvic  structures,  would  tend  to  produce  the 
constriction.  In  the  majority  of  the  reported  cases  there  have  been  no  adhesions, 
hence  it  would  seem  that  the  factor  most  important  in  the  etiology  of  this  condition 
is  dilatation  of  the  stomach. 

The  symptoms  of  the  condition  are  vomiting  large  quantities  of  fluid,  eructa- 
tion of  gas,  and  collapse.  The  temperature  is  not  elevated,  the  pulse  is  rapid,  and 
there  is,  generally,  restlessness  and  some  difficulty  in  breathing.  Examination  of 
the  abdomen  shows  distention  in  the  region  of  the  stomach.  There  is,  as  a  rule, 
no  visible  peristalsis.  Once  one's  attention  is  directed  toward  the  condition  little 
trouble  should  be  experienced  in  making  a  diagnosis  unless  there  is  at  the  same 
time  a  distention  of  the  intestines. 

The  treatment  consists  in  emptying  the  stomach  and  keeping  it  empty  by  means 
of  the  stomach-tube,  and  putting  the  patient  in  the  elevated  hip  position  to  favor 
the  gravitation  of  the  stomach  and  intestines  toward  the  diaphragm.  Dilatation 
of  the  vagina  and  rectum  with  air  while  the  patient  is  in  the  knee-chest  or  elevated 
hip  position  would  promote  the  same  results.  Rectal  alimentation  should  be 
resorted  to  for  a  few  days.  After  the  vomiting  subsides  gradual  stomach-feeding 
can  be  resumed.  Strychnin,  atropin,  or  eserin  would  seem  to  be  indicated.  The 
bowels  should  be  emptied  by  means  of  enemata  alone  until  the  stomach  returns 
to  a  fairlv  normal  condition. 


POST-OPERATIVE    COMPLICATIONS    INVOLVING    BRONCHI,    LUNGS,    ETC.  35 

POST-OPERATIVE  COMPLICATIONS  INVOLVING  THE  BRONCHI,  LUNGS,   ETC. 

Among  the  most  frequent  and  serious  complications  which  arise  after  operations 
are  inflammatory  conditions  of  the  bronchi  and  kmgs.  The  most  important  of 
these  are  bronchitis,  pneumonia,  pleurisy,  acute  edema,  gangrene  and  abscess  of 
the  lungs,  pulmonary  embolus,  and  the  lighting  up  of  chronic  tuberculous  proc- 
esses. 

The  role  played  by  the  anesthetic  in  the  etiology  of  these  diseases  has  never 
been  satisfactorily  determined.  Before  the  discovery  of  anesthesia  lung  complica- 
tions caused  a  high  mortality  after  operation,  and  some  recent  statistics  of  v.  jNIiku- 
licz  and  other  German  writers  are  extremely  interesting  as  bearing  upon  the  role 
played  by  ether  and  chloroform  in  the  causation  of  such  complications.  Mikulicz^ 
states  that,  at  the  Breslau  clinic  in  1005  laparotomies  and  operations  for  strumous 
affections  under  general  anesthesia,  there  was  a  pneumonic  morbidity  of  7.5  per  cent, 
with  a  mortality  of  3.4  per  cent.  In  273  cases  operated  upon  under  local  anesthesia 
(Schleich's  method)  there  was  a  morbidity  of  12.8  per  cent,  and  a  mortality  of  4.8 
per  cent,  due  to  pneumonia.  This  increase,  he  thinks,  was  due  to  the  nature  of 
the  operation  and  of  the  disease  from  which  the  patient  was  suffering,  his  cases 
where  local  anesthesia  was  employed  being  from  the  onset  more  prone  to  lung 
affections  than  those  where  ether  or  chloroform  was  used.  There  are  other  statis- 
tics which  are  equally  striking,  and  they  all  emphasize  the  fact  that  a  large  pro- 
portion of  the  more  serious  lung  complications  after  operations  are  not  due  to  the 
action  of  the  anesthetic. 

I  have  been  unable  to  find  satisfactory  statistics  as  to  the  relative  frequency  of 
the  different  pulmonary  and  bronchial  complications  after  operations.  In-  approxi- 
mately 8000  to  9000  cases  of  general  anesthesia,  of  which  7000  were  operations, 
in  the  gynecologic  department  (Kelly's  clinic)  of  the  Johns  Hopkins  Hospital  prior 
to  1901,  there  were  17  cases  of  pneumonia,  18  of  bronchitis  without  other  lung 
affections,  16  of  pleurisy,  6  of  recognized  pulmonary  embolism,  and  one  case  of 
gangrene  of  the  lungs.  These  statistics,  while  not  extremely  accurate,  are  as  much 
so  as  statistics  of  the  kind  can  be.  It  is  not  possible  to  always-  recognize  the  exact 
lesion  in  cases  of  the  kind  which  recover,  and  many  of  those  who  die  do  not  come 
to  autopsy.  In  most  of  these  cases  the  diagnosis  was  made  after  consultation  with 
experts  in  physical  diagnosis,  and  the  symptoms,  as  stated  in  the  notes,  have  been 
carefully  compared  with  the  diagnosis.  Where  autopsies  took  place  the  anatomic 
diagnosis  was  taken.  According  to  the  above  statistics,  pneumonia  occurred  once 
in  every  523  cases  of  general  anesthesia;  pleurisy,  once  in  566  cases;  bronchitis, 
once  in  500;  and  pulmonary  embolism,  once  in  every  1333  cases.  Robb  and 
Dittrick  in  1007  abdominal  operations  found  that  35  cases  developed  post-oper- 
ative inflammatory  lesions  of  the  respiratory  tract.  Of  these  35  cases,  18  had 
bronchitis,  9  pleurisy,  3  acute  pulmonary  tuberculosis,  and  3  bronchopneumonia. 

W.  Mikulicz,  J.:  "Pneumonie,"  Verhand.  d.  XXX  Kongr.  der  Deutsche  Gesellsch.  f.  Chir.. 
Centralbl.  f.  Chir.,  No.  29,  1901,  p.  16. 


36  COMPLICATIONS   FOLLOWING    OPERATIONS. 

Gerulanos^  states  that  in  the  surgical  cHnic  at  Kiel,  7  of  95  deaths  occurring  after 
operations  were  due  directly  to  lung  complications.  In  1196  laparotomies  in  the 
Munich  surgical  clinic  there  were  77  cases  of  post-operative  lung  affections  with  63 
deaths.^  BibergeiP  found  in  3909  abdominal  operations  283  post-operative  lung 
complications. 

There  are  some  observations  which  apply  more  or  less  to  all  of  the  post-operative 
lung  complications.  The  immediate  effects  of  the  anesthetic,  especially  ether, 
upon  the  mucous  membrane  of  the  air-passages  are  doubtless  largely  responsible 
for  many  cases  of  bronchitis  and  edema  of  the  lung.  Lindeman  (cited  by  Geru- 
lanos)  and  Holscher,^  however,  could  not  find  in  their  experiments  upon  animals 
that  ether  produced  an  inflammatory  action  upon  the  lung  itself.  Chilling  or  catch- 
ing cold,  either  through  exposure  in  a  cool  operating  room  or  after  leaving  a  heated 
operating  room  and  returning  to  a  cold  ward,  is  in  many  cases  responsible  for  pul- 
monary affections.  Holscher  estimates  that  a  patient  loses  from  0.1°  to  3°  C.  during 
anesthesia,  according  to  the  length  of  time  and  the  condition  of  the  patient.  Weak 
and  feverish  patients,  according  to  him,  lose  more  than  strong  and  robust  ones. 
This  loss  of  heat  would  render  the  patient  liable  to  pneumonia,  bronchitis,  etc., 
unless  great  care  were  taken  to  protect  her.  The  aspiration  of  mucus,  vomitus, 
and  saliva  with  the  bacteria  of  the  mouth  and  pharynx  is  responsible  for  many 
cases  of  affections  of  the  lungs,  bronchi,  etc.,  which  occur  after  operation.  The 
congestion  of  the  lungs  caused  by  weak  circulation,  the  recumbent  posture,  and  the 
want  of  proper  expansion  of  the  chest  and  the  aeration  of  the  lungs  due  to  weakness, 
pain,  tight  bandaging,  and  distended  intestines,  prepare  the  ground  for  the  infec- 
tion. The  excitement  before  the  operation,  the  anxiety  and  unrest,  not  only  cause 
the  patient  to  take  the  anesthetic  worse  than  she  otherwise  would,  but  by  producing 
a  generally  depressed  condition  render  her  more  susceptible  to  other  influences, 
such  as  cold.  The  amount  and  character  of  the  anesthetic,  the  skill  with  which 
it  is  given,  and  the  time  of  anesthesia  play  important  parts.  Alcoholic,  fat,  and 
plethoric  patients  require  more  of  the  anesthetic  and  are  more  apt  to  suffer  with 
lung  complications.  Preexisting  pulmonary  or  bronchial  disease  plays  an  impor- 
tant role  also  in  the  causation  of  serious  lung  complications  after  operation.  The 
nature  of  the  operation  likewise  seems  to  play  an  important  role  in  the  causation 
of  lung  affections,  certain  operations,  as  those  for  strangulated  hernia,  being  more  apt 
to  be  followed  by  pneumonia,  and  those  for  myomata,  etc.,  by  pulmonary  embolism. 
The  frequency  and  importance  of  the  smaller  pulmonary  emboli  which  do  not  cause 
instant  death  are  underestimated  by  most  observers,  many  of  the  post-operative 
pulmonary  affections  being  of  embolic  origin.     The  long  continuance  in  the  Tren- 

1  Gerulanos,  M.:  " Lungencomplicationen  nach  Operativen  Eingriffen,"  Deutsche  Zeitschr.  f. 
Chir.,  Leipz.,  1900,  Ivii,  361-382. 

^Gebele:  "Ueber  embolische  Lungen  affektionen  nach  Bauch-operationen,"  Beitr.  z.  klin. 
Chir.,  xhii,  Hft.  2.  251-318. 

3  Cited  from  Zentralbl.  f.  Gyn.,  Nr.  34,  1906. 

*  Holscher,  R.:  ''Experimentelle  Untersuchungen  iiber  die  Entstehung  der  Erkrankungen 
der  Luftwege  nach  Aether  narkose,"  Archiv  f.  kUn.  Chir.,  Ivii,  175. 


POST-OPERATIVE    COMPLICATIONS   INVOLVING    BRONCHI,    LUNGS,    ETC.  37 

delenburg  position  is  thought  by  many  to  be  productive  of  harm:  the  abdominal 
viscera  press  against  the  diaphragm  and  impede  its  free  movements  and  the  gravita- 
tion of  blood  to  the  most  dependent  parts  would  tend  to  cause  pulmonary  congestion. 

Pneumonia. — The  frequency  of  the  occurrence  of  pneumonia  apparently 
varies  in  different  countries  and  in  different  clinics  in  the  same  country.  This 
difference  may  be  partly  real,  but  is  in  greater  part  only  apparent.  The  difficulty 
in  getting  statistics  is  obvious.  It  is  not  always  possible  to  differentiate  small 
bronchopneumonic  areas  from  localized  tuberculous  processes,  hemorrhagic  in- 
farcts, etc.,  and  cases  come  to  autopsy  with  post-operative  pneumonia  when  the 
condition  was  not  recognized  during  life.  In  this  country  a  great  many  cases  who 
die  never  come  to  autopsy,  and  we  have  to  depend  upon  a  clinical  diagnosis.  The 
number  of  the  cases  of  pneumonia  following  operation  depends  also  upon  the  nature 
of  the  operation,  the  methods  of  operating,  the  country,  the  season  of  the  year, 
the  anesthetic  employed,  and  the  manner  in  which  it  is  given.  Anders^  found  in 
12,842  cases  of  ether  narcosis  in  Philadelphia  30  cases  of  pneumonia  and  13  deaths. 
Prescott  (cited  by  Osier),  in  Boston,  in  40,000  similar  cases  found  only  3  cases  of 
acute  lobar  pneumonia.  Henle^  in  von  Mikulicz's  clinic  in  Breslau  reports,  in  1787 
cases  of  laparotomy  and  operations  for  hernia,  143  post-operative  pneumonias 
with  65  deaths,  and  in  200  amputations  of  the  breast  2  pneumonias  and  one  death. 
In  Gebele's  1196  laparotomies  with  77  cases  where  lung  complications  followed, 
20  of  these  were  regarded  as  hypostatic  pneumonias,  8  as  ether  pneumonias,  26  as 
aspiration  pneumonias,  and  in  14  the  process  was  embolic  in  character.  Pietrzi- 
kowski  (cited  by  Gebele)  reported  13  cases  of  pneumonia  following  210  operations 
for  incarcerated  hernise.  Czerny,  of  Heidelberg,  reports  52  cases  of  pneumonia  in 
1300  laparotomies.  Trendelenburg,  of  Leipzig,  reports  that  pneumoni-a  follows 
laparotomies  in  about  5  per  cent,  of  cases.  According  to  his  observations,  gastros- 
tomies were  complicated  by  pneumonia  in  3  per  cent.;  operations  on  the  bile- 
passages,  6.4  per  cent. ;  appendicitis,  5  per  cent.,  and  exploratory  laparotomies  in  4.7 
per  cent.  Mallett^  reports  seven  cases  of  "non-septic  pneumonia"  in  1700  laparot- 
omies. In  8000  to  9000  cases  of  anesthesia,  representing  7000  operations  in  the 
gynecologic  clinic  of  the  Johns  Hopkins  Hospital,  there  were  17-cases  of  pneumonia. 

Lobar  pneumonia  is  relatively  less  frequent  than  bronchopneumonia.  In  Henle's 
cases,  of  those  which  came  to  autopsy  7  were  acute  lobar  pneumonias,  24  lobular 
or  bronchopneumonias,  and  17  pulmonary  gangrene.  In  Gerulianos'  7  cases  5 
were  bronchopneumonias,  one  gangrene,  and  one  a  pulmonary  infarct.  In  17 
cases  of  Bloodgood's,  reported  by  Osier,  13  were  bronchopneumonias  and  3  lobar 
pneumonias.  Kummell  reports  1070  laparotomies  with  8  lobar  and  21  broncho- 
pneumonias. In  the  Johns  Hopkins  Hospital  cases  previously  referred  to,  9  were 
lobar  pneumonias  and  8  bronchopneumonias,  one  of  the  latter  finally  resulting 
in  gangrene. 

1  Anders,  J.  M.:  "Ether  Pneumonia,"  Univ.  Med.  Mag.,  Phila.,  1897-98,  x,  641-663. 
^  Henle:  "Ueber  Pneumonie  und  Laparotomie,"  Archiv  f.  klin.  Chir.,  xliv,  Hft.  2. 
3  Mallett,  G.  H.:  Trans.  N.  Y.  Obst.  Soc,  Am.  Jour.  Obst.,  April,  1905.  p.  516. 


38  COMPLICATIONS    FOLLOWING    OPERATIONS. 

The  causes  of  pneumonia  following  operation  may  be  divided  into  the  predis- 
posing and  the  exciting.  The  predisposing  causes  are  old  age;  intemperance; 
weakness  or  disease  of  the  heart  and  blood-vessels,  and  disease  of  the  kidneys;  the 
recumbent  posture;  the  inability  to  cough  up  foreign  substances,  and  the  imperfect 
expansion  of  the  lungs  on  account  of  pain,  distention  of  the  intestines,  tight  ban- 
daging, coma,  and  the  use  of  narcotics;  edema  of  the  lungs  caused  by  the  anesthetic; 
excitement,  shock,  etc.;  preexisting  disease  of  the  lungs,  bronchi,  nose,  or  mouth; 
chilling  of  the  body  during  or  after  operation;  and  the  presence  of  foreign  substances, 
such  as  mucus  and  vomitus.  Pulmonary  infarcts  probably  act  as  the  starting-point 
of  a  pneumonia  in  a  certain  number  of  cases.  Pietrzikowski  believed  that  in  13 
cases  of  post-operative  pneumonia  the  process  had  its  origin  in  an  infarct,  while 
Bebele  believes  that  one-third  of  the  cases  of  infarct  are  followed  by  pneumonia. 
The  exciting  cause  is  bacteria  which  gain  access  by  aspiration  of  foreign  substances 
and  through  the  blood-channels  and  hinph-channels.  Infected  emboli  may  carry 
the  bacteria  or  the  latter  may  gain  access  through  the  blood-vessels  and  lymph- 
vessels  without  the  aid  of  the  former.  When  the  emboli  come  from  the  ovarian  or 
branches  of  the  iliac  veins  the  emboli  pass  through  the  right  heart  directly  to  the 
lungs,  but  when  from  the  branches  of  the  portal  vein  they  lodge,  as  a  rule,  in  the 
liver,  from  which  point  secondary  emboli  may  pass  to  the  lungs.  A  direct  embolus 
can  pass  to  the  lungs  from  the  portal  vein  only  l)y  anastomosis  between  this  vessel 
and  the  inferior  vena  cava.  The  bacteria  which  are  found  to  be  the  cause  of  post- 
operative pneumonia  are  the  ^Micrococcus  lanceolatus,  the  pyogenetic  cocci,  the 
Bacillus  coli  communis,  the  Bacillus  pneumoniae  of  Friedlander,  and  others. 

In  our  cases  age  and  season  of  the  year  did  not  seem  to  play  important  parts  in 
the  causation  of  the  disease.  The  nature  of  the  operation  seemed  more  important, 
most  of  the  cases  having  followed  serious  laparotomies. 

Symptoms. — In  the  cases  of  lobar  pneumonia  the  s\Tiiptoms,  as  a  rule,  appeared 
a  short  time  after  operation,  some  within  twelve  hours.  The  disease  usually  ran  a 
typical  course,  beginning  with  a  chill.  There  was  a  sudden  rise  of  temperature  to 
104°  or  105°  F.,  rapid  pulse,  cough  with  the  characteristic  sputum,  pain  in  the  chest, 
dyspnea  or  hurried  respirations,  and  the  disease  usually  ended  by  crisis.  The 
physical  signs  were  usually  unmistakable.  The  s^onptoms  of  hronchopneumonia 
were  not  so  definite.  In  these  cases  the  symptoms  came  on  later,  and  it  was  usually 
several  days  before  a  diagnosis  could  be  made  with  any  degree  of  certainty.  The 
temperature  was  not  high  and  was  somewhat  irregular  in  its  nature,  there  were  gen- 
erally bronchitis,  cough,  frequently  blood-stained  sputum,  and  rather  indefinite 
physical  signs.     The  cases,  as  a  rule,  ended  by  lysis. 

Treatment. — The  prophylactic  treatment  will  alone  be  considered.  The  three 
things  of  most  importance  are:  (1)  the  careful  examination  of  the  patient's  chest 
to  detect  diseases  of  the  Vjronchi,  lungs,  and  heart  before  the  administration  of  the 
anesthetic;  (2)  the  proper  administration  of  the  anesthetic;  and  (3)  guarding  the 
patient  against  chilling.  In  most  cases  it  is  possible,  by  proper  administration  of 
the  anesthetic,  to  prevent  the  collection  and  aspiration  of  mucus,  vomitus,  etc. 


POST-OPERATIVE    COMPLICATIOXS    IXVOLVIXG    BRONCHI,    LUNGS,    ETC.  39 

She  should  be  protected  against  loss  of  heat  by  a  properly  heated  operating  room 
and  ward,  the  protection  of  the  intestine  by  means  of  a  warm  gauze,  and  having 
her  body  well  protected,  both  during  operation  and  afterward.  Some  surgeons 
employ  operating  tables  which  are  heated,  and  claim  by  their  use  to  have  lessened 
their  mortality.  Before  1898  in  ^Mikulicz's  clinic  the  percentage  of  pneumonias 
was  8  to  10,  which  sank  to  6.6  in  1899  and  3.6  in  1900,  following  the  introduction 
of  the  heated  table.  Rapidity  in  operating,  proper  skill  and  care  in  the  administra- 
tion of  and  the  reduction  to  the  smallest  possible  quantity  of  the  amount  of  the 
anesthetic  are  very  important.  In  cases  of  strangulated  hernia,  and  when  the 
patient  is  very  weak  or  has  chronic  disease  of  the  bronchi  and  lungs,  local  anesthesia 
is  indicated;  but  the  more  serious  operations,  especially  in  nervous,  excitable 
women,  should  always  be  performed  under  general  anesthesia.  \Yhere  the  stomach 
is  full  it  is  well  to  wash  it  out  before  operation.  Cleansing  the  mouth,  throat,  etc., 
prior  to  operation  is  probably  of  little  value.  The  administration  of  a  small  hypo- 
dermic injection  of  morphin  and  atropin  a  short  time  before  the  operation  tends  to 
put  the  patient  in  a  more  quiet  frame  of  mind  and  to  lessen  the  amount  of  secretion 
from  the  mouth,  etc.  After  operation  the  patient  should  be  frequently  turned  in 
bed,  the  bandaging  should  not  constrict  the  abdomen  or  chest,  she  should  be  en- 
couraged to  breathe  deeply,  and  to  cough  up  any  material  which  had  been  taken 
into  the  lungs  by  aspiration. 

Pulmonary  Embolism. — This  affection  has  been  considered  under  Embolism. 
In  Gebele's  1196  laparotomies,  14  cases  of  pulmonary  embolism  occurred.  Burk- 
hard  in  236  myoma  operations  saw  12  cases  of  post-operative  pulmonary  embolism. 
Pietrzikowski  in  210  cases  of  incarcerated  hernia  saw  14  cases  of  what  he  consid- 
ered a  hemorrhagic  infarct  following  the  operation.  According  to  our  statistics, 
there  have  been  only  6  cases  of  known  pulmonary  embolism  after  7000  operations. 
As  we  will  show  when  considering  "pleurisy,"  the  occurrence  of  small  emboli  is 
much  more  common  than  is  shown  by  the  figures  above.  Four  of  our  cases  died 
and  the  other  two  recovered,  although  the  signs  of  embolism  were  cjuite  marked. 
One  case  was  so  typical  and  shows  so  plainly  the  connection  between  thrombosis, 
pulmonary  embolism,  and  the  so-called  post-operative  pleurisy  that  I  give  it  some- 
what in  detail. 

"Mrs.  C .  Operation:  Hysteromyomectomy  (May  11,  1895).  No  com- 
plication— easy  operation. 

"  May  18th. — Sudden  attack  of  sharp  pain  over  a  localized  area  in  the  left  chest. 
This  was  increased  by  deep  inspiration.  Temp.  103°  F.,  pulse  104,  dry  cough. 
Physical  examination  showed  a  pleuritic  friction  sound  in  region  of  pain,  the  other 
signs  being  indefinite. 

"The  pain  decreased  and  the  signs  of  pleurisy  had  disappeared  by  ^Nlay  24th. 

*'  May  29fh. — ^Yhile  using  a  bed-pan  she  was  suddenly  seized  with  a  fainting 
spell  and  complained  of  a  feeling  of  oppression  over  the  sternum.  The  physical  ex- 
amination of  the  chest  was  negative.  Pulse  120,  feeble.  Her  symptoms  increased, 
and  in  a  few"  hours  she  was  suffering  from  dyspnea,  a  heaw  aching  pain  over  the 
sternum,  ringing  in  the  ears  and  dark  spots  before  the  eyes,  cold  and  clammy 


40  COMPLICATIONS   FOLLOWING    OPERATIONS. 

extremities.  The  pulse  was  140  and  the  heart's  action  tumultuous.  (Under  a  mis- 
taken diagnosis  of  hemorrhage,  an  exploratory  laparotomy  was  performed,  but 
nothing  was  found  to  account  for  the  symptoms.) 

"May  30th. — Patient  better.  Pain  in  chest  continues.  Pulse  120.  Pain  is 
complained  of  in  the  left  leg. 

"May  31st. — Well-marked  symptoms  of  phlebitis  in  left  leg. 

"June  1th. — Phlebitis  in  right  leg." 

The  patient  eventually  recovered.  In  this  case  there  was  probably  a  thrombus 
in  one  of  the  pelvic  veins  which  extended  to  the  iliac  and  finally  caused  the  so-called 
phlebitis.  The  attack  of  supposed  pleurisy  was  undoubtedly  an  infarct  from  a 
small  embolus  and  the  second  attack  a  typical  one  of  pulmonary  embolus,  which 
probably  partially  plugged  a  larger  vessel. 

In  one  of  the  fatal  cases  the  symptoms  grew  less  marked  after  a  few  hours. 
Examination  of  the  chest  showed  stridulous  breathing  and  tumultuous  heart  action, 
but  was  otherwise  negative.  She  died  at  the  end  of  twelve  hours.  Cases  have  been 
reported  where  the  patient  lived  several  days  after  the  occurrence  of  the  embolism, 
and  a  small  percentage  end  in  recovery. 

Pleurisy. — Acute  pleurisy  occurring  after  operation  and  independent  of  pneu- 
monia and  tuberculosis  is  less  frequent  than  would  appear  at  first  sight.  Most 
cases  where  there  is  severe  pain  in  the  chest  accompanied  with  a  pleuritic  friction 
rub  and  without  definite  signs  of  pneumonia  are  diagnosed  as  pleurisy.  In  the 
majority  of  these  cases  the  pleurisy  is  secondary  to  some  other  process,  as  hemor- 
rhagic infarct  or  a  small  spot  of  bronchopneumonia.  The  relation  which  exists 
between  pleurisy  and  embolism  is  strikingly  illustrated  in  our  cases.  In  the  16 
cases  of  so-called  pleurisy  which  have  been  previously  mentioned,  in  only  one  was 
there  an  effusion,  and  in  more  than  one-half  of  them  there  were  either  evidences  of 
a  thrombus  or  signs  of  an  embolus.  The  case  cited  under  Pulmonary  Embolism 
illustrates  very  forcibly  the  relationship  existing  between  the  two  affections.  The 
following  are  some  of  the  cases  of  pleurisy  which  show  the  same  relationship : 

Case  2:  Phlebitis  followed  in  seven  days  by  pleurisy 

Case  3 :  Signs  of  pleurisy  with  a  phlebitis  on  the  following  day. 

Case  4:  Phlebitis  followed  in  one  month  by  pleurisy  (localized). 

Case  5 :  Pleurisy  on  the  tenth  day.  Edema  of  legs  on  sixteenth  and  seventeenth 
day  respectively. 

Case  6 :  Phlebitis  on  twenty-third  day  and  pleurisy  on  twenth-eighth  day  after 
operation. 

Case  7:  Pleurisy  with  signs  of  pulmonary  embolism,  i.  e.,  sudden  dyspnea,  cya- 
nosis, rapid  pulse,  cold  extremities. 

Case  8:  Pleurisy  (?)  developed  eleven  days  after  operation.  This  gradually 
cleared  up,  and  on  the  twenty-seventh  day  as  she  was  leaving  hospital  she  fell  over 
and  expired.     No  autopsy  allowed,  but  the  diagnosis  was  "pulmonary  embolus." 

A  certain  number  of  cases  of  pleurisy  are  tuberculous  in  origin,  but  the  propor- 
tion of  such  cases  after  operation  is  smaller  than  that  seen  in  general  medical 
wards.     Cases  of  pleurisy  arise,  also,  which  are  not  due  to  pneumonic  areas  in  the 


POST-OPERATIVE    COMPLICATIONS   INVOLVING    BRONCHI,    LUNGS,    ETC.  41 

lung,  but  owing  to  the  fact  that  nearly  all  recover  it  is  difficult  to  estimate  the  correct 
proportion  of  the  different  varieties.  A  certain  number  of  cases  of  pleurisy  are  due 
to  an  extension  of  an  infection  through  the  diaphragm.  These  forms  of  pleurisy 
occur  most  frequently  in  cases  of  subphrenic  and  liver  abscess. 

The  symptoms  and  treatment  will  not  be  dwelt  on  here.  In  a  few  cases  arising 
in  our  wards  the  diagnosis  wavered  between  diaphragmatic  pleurisy  and  gall-stones. 

Gangrene  of  the  lungs  is  a  rare  post-operative  complication  of  gynecologic 
operations,  and  is  generally  the  result  of  aspiration  of  vomited  material  during 
anesthesia.  It  may  occur  from  the  same  cause  in  very  weak  or  unconscious  patients. 
At  times  it  results  from  emboli  which  arise  from  gangrenous  wounds  or  from  the 
infection  of  an  infarct  with  the  putrefactive  bacteria.  The  symptoms  vary  consid- 
erably and  will  not  be  gone  into  here.  The  diagnosis  is  largely  based  upon  the 
character  of  the  expectoration,  which  is  intensely  fetid  and  usually  of  a  greenish 
color.  The  German  writers  apparently  meet  with  it  more  often  than  is  the  case  in 
America.  From  the  statistics  given  before,  it  seems  not  an  unusual  complication 
in  some  of  their  clinics,  while  only  one  known  case  was  seen  following  7000  opera- 
tions in  the  gynecologic  wards  of  the  Johns  Hopkins  Hospital. 

Abscesses  of  the  lungs  are  even  less  common  than  gangrene  except  as  an 
accompaniment  of  pyemia  or  an  extension  from  some  neighboring  organ.  The 
causes  are  the  same  as  gangrene,  with  the  absence  of  the  putrefactive  bacteria. 
Hence  it  is  most  often  found  in  cases  of  pyemia  and  not  as  the  result  of  an  aspiration 
pneumonia. 

Edema  of  the  lungs  to  a  greater  or  less  extent  occurs  in  all  forms  of  intense 
congestion  and  inflammation.  General  edema  occurring  after  operation  is  stated 
to  have  for  its  causes  the  direct  action  of  the  anesthetic  upon  the  lung  and  a  depres- 
sion or  paralysis  of  the  vasomotor  center.  Disease  of  the  heart  and  kidneys  is  a 
predisposing  cause.  The  intravenous  use  of  salt  solution  in  large  amounts  is  con- 
ducive to  the  affection.  Noble  says  that,  since  using  salt  solution  freely,  and  especi- 
ally since  elevating  the  foot  of  the  bed  with  the  peritoneal  cavity  full  of  this  solution, 
he  has  had  six  cases  of  pulmonary  edema.  While  he  does  not  assert  that  the  edema 
is  due  to  the  posture  and  use  of  the  saline,  he  thinks  the  frequent  occurrence  of 
edema  very  suggestive.  Overfilling  the  blood-vessels,  diluting  the  blood,  and 
giving  the  patient  a  posture  which  tends  to  compress  the  lungs  and  embarrass  the 
heart  would,  theoretically,  tend  to  cause  an  edematous  condition  of  the  lungs.  The 
principal  symptoms  are  dyspnea  and  cough.  The  physical  signs  are  indefinite, 
there  being  usually  defective  resonance  and  large  liquid  rales  over  the  bases.  In 
acute  cases  active  purgation  and  venesection  are  indicated.  Cardiac  stimulants 
should  be  freely  used. 

Pulmonary  tuberculosis  as  a  post-operative  affection  is  not  well  worked  up. 
The  conditions  of  the  lungs  which  favor  its  development  are  generally  present  after 
a  serious  operation.  Doubtless  many  cases  have  had  surgical  operations  as  their 
starting-point,  but  it  would  appear  that  in  more,  the  acute  tuberculous  process  is  a 
lighting  up  of  a  preexisting  lesion.     The  encapsulated  or  quiescent  tuberculous 


42  COMPLICATIONS   FOLLOWING   OPERATIONS. 

nodule  becomes  the  starting-point  of  a  more  serious  lesion.  I  have  seen  two  cases 
of  acute  pulmonary  tuberculosis  following  simple  hernia  operations.  They  both 
came  to  autopsy  within  six  weeks  after  operation. 

It  is  often  necessary  to  operate  upon  patients  that  are  known  to  have  chronic 
pulmonary  tuberculosis.  In  these  cases  local  anesthesia  should  always,  where 
possible,  be  employed,  and  when  necessary  to  use  chloroform  or  ether  the  former  is 
to  be  chosen. 

Acute  Bronchitis. — This  is  one  of  the  most  frequent  affections  of  the  air- 
passages  which  follow  anesthesia.  It  generally  accompanies  pneumonia,  but 
appears  also  quite  frequently  as  an  independent  affection.  There  were  eighteen 
cases  among  our  patients  which  were  quite  independent  of  any  signs  of  pneumonia, 
etc. 

The  causes  are  the  immediate  effects  of  the  anesthetic,  especially  ether;  the 
existence  of  chronic  bronchitis;  catching  cold  during  or  after  operation;  and  the 
aspiration  of  mucus  and  vomitus  during  narcosis. 

The  symptoms  and  treatment  are  those  of  ordinary  bronchitis.  The  prophyl- 
axis is  most  important,  special  attention  being  given  to  prevent  chilling  of  the  body 
in  a  cold  operating  room  or  having  the  patient  not  sufficiently  protected  in  moving 
her  from  the  operating  room  to  the  ward.  The  coughing,  frequently  severe,  causes 
pain  in  those  patients  who  have  an  abdominal  incision,  and  the  remedies  which  check 
the  cough  are  contraindicated  to  a  certain  extent,  as  the  accumulation  of  the  irritat- 
ing substances  is  a  frequent  cause  of  bronchopneumonia.  The  violent  coughing 
has  in  a  few  cases  caused  a  separation  of  the  edges  of  the  incision. 


POST-OPERATIVE  COMPLICATIONS  CONNECTED  WITH  THE  BLADDER, 

KIDNEYS,  ETC. 

Numerous  complications  connected  with  the  urinary  tract  may  arise  after  gyne- 
cologic operations,  the  chief  of  these  being  retention  and  incontinence  of  urine, 
cystitis,  suppression  of  urine,  nephritis,  hemorrhage  into  the  kidney  or  bladder, 
fistulas  (renal,  ureteral,  or  vesical),  pyonephrosis  and  hydronephrosis. 

Retention  of  Urine. — The  inability  to  void  the  urine  occurs  quite  frequently 
after  operation.  The  necessity  for  catheterization  a  few  times  after  operation 
arises  in  at  least  one-half  of  the  cases  of  laparotomy,  and  with  some  patients  the 
catheter  has  to  be  used  for  weeks.  The  dorsal  posture  is  to  a  large  extent  responsi- 
ble for  this  inability  to  empty  the  bladder.  The  pain  which  is  caused  by  the  mus- 
cular effort  in  straining  frequently  prevents  the  patient  from  voiding,  while  a  ure- 
thritis or  an  operation  which  involves  the  urethra  or  bladder  is,  at  times,  the  cause 
of  the  retention.  Hysteria  and  nervousness  are  likewise  factors.  Vaginal  packs, 
clamps,  etc.,  which  compress  the  urethra  may  make  it  impossible  to  pass  the  urine 
until  they  are  removed.  Occasionally  a  condition  exists  in  which  the  patient  voids 
her  urine  but  the  bladder  is  not  emptied  by  the  act.  In  such  a  case  the  residual 
urine  is  liable  to  undergo  decomposition,  cause  a  cystitis,  or  even  produce  a  hydrone- 


POST-OPERATIVE  COMPLICATIONS  CONNECTED  WITH  BLADDER,  KIDNEYS,  ETC.     43 

phrosis  or  pyelitis.  This  dilatation  of  the  bladder  is  indicated  by  a  frequent  desire 
to  urinate,  discomfort  in  the  region  of  the  bladder,  and  the  presence  of  a  tumor 
just  above  the  symphysis.  The  passage  of  a  catheter  will  clear  up  any  doubt  which 
may  exist  as  to  the  diagnosis. 

Treatment. — As  the  cause  of  cystitis  in  a  large  percentage  of  all  cases  can  be 
traced  to  the  use  of  the  catheter,  it  is  evident  that  catheterization  should,  if  possible, 
be  avoided.  In  minor  operations,  such  as  dilatation  and  curetage,  it  is  well  in  most 
cases  to  allow  the  patient  to  sit  up  in  bed,  in  which  position  she  can  usually  pass 
her  urine.  In  cases  away  from  hospitals,  and  where  the  services  of  a  doctor  or 
competent  nurse  cannot  be  had  when  wanted,  the  management  of  this  affection  be- 
comes quite  a  problem.  After  perineorrhaphy  and  other  operations  where  there  is 
little  likelihood  of  secondary  hemorrhage  or  embolus,  it  is  advisable,  at  times,  to 
have  the  patient  lifted  to  a  knee-elbow  position,  when  she  can  usually  pass  her  urine 
without  difficulty.  In  all  cases  the  patient  should  be  encouraged  to  void  by  having 
the  bed-pan  placed  under  her  and  allowing  a  stream  of  warm  water  to  play  over 
the  external  genitalia.  In  those  where  there  is  no  abdominal  incision  she  should 
aid  herself  by  making  pressure  over  the  bladder  above  the  symphysis.  In  case  it  is 
necessary  to  use  the  catheter  the  most  rigorous  precautions  should  be  enforced  to 
prevent  carrying  in  bacteria,  and  injuring  the  urethral  or  bladder  mucosa.  Never- 
theless cystitis  will  arise  under  favorable  conditions  in  spite  of  the  most  rigid  care 
on  the  part  of  the  nurse. 

Incontinence  of  urine  may  occur  after  operation  and  is,  at  times,  a  sign  of  an 
overdistended  bladder.  As  a  rule,  the  constant  passage  of  the  urine  indicates 
that  an  opening  has  been  made  in  the  bladder  or  that  one  or  both  ureters  have  been 
injured.  This  accident  not  infrequently  happens  after  pan-hysterectomy  and  other 
operations  upon  the  pelvic  organs  in  which  the  vagina  has  been  opened.  Another 
occasional  cause  of  incontinence  is  over-dilatation  of  the  urethra.  The  female 
urethra  measures  on  an  average  7.59  mm.  in  diameter,^  and  while  it  is,  in  most 
cases,  possible  to  dilate  it  to  admit  without  injury  a  speculum  or  sound  10  mm.  in 
diameter,  if  the  dilatation  is  carried  much  beyond  this  point  the  sphincter  of  the 
urethra  is  so  stretched  that  it  frequently  loses  its  power  of  contraction  for  some  days 
and  incontinence  ensues.  The  dilatation  of  the  urethra  to  admit  the  finger  is 
justifiable  only  in  extreme  cases.  Severe  cystitis,  new-growths,  and  undue  pressure 
on  the  bladder  from  exudates,  etc.,  are  also  causes  of  incontinence. 

Treatment. — There  are  two  indications  for  treatment:  viz.,  (1)  to  remove  the 
cause,  and  (2)  to  prevent  excoriation  of  the  genitalia  and  infection  of  the  bladder 
by  means  of  scrupulous  cleanliness,  boric  washes,  the  application  of  zinc  ointment, 
or,  more  useful  than  all,  the  continuous  bath.  Many  patients  remain  in  the  bath 
day  and  night  without  discomfort,  while  others  do  better  if  allowed  to  remain  out  at 
night. 

Post-Operative  Cystitis. — The  general  consideration  of  cystitis  is  found  in 

*  Miller,  G.  Brown:  "Measurement  of  the  External  Urethral  Orifice."  Johns  Hopkins  Hosp. 
Bull.,  Aug.,  1901,  251-252. 


44  COMPLICATIONS   FOLLOWING    OPERATIONS. 

another  chapter  in  this  book,  but  the  affection  occurs  so  frequently  as  a  post-opera- 
tive compUcation  that  a  brief  notice  of  it  here  will  not  be  out  of  place.  It  is  one  of 
the  most  distressing  as  well  as  one  of  the  most  frequent  of  the  complications  which 
follow  gynecologic  operations.  Cases  which  resist  treatment  for  months  and  years 
occur  after  the  simplest  operations,  such  as  perineorrhaphy,  suspension  of  the 
uterus,  etc. 

Causes. — Cystitis  can  follow  the  internal  administration  of  certain  drugs,  as 
cantharides.  Cases  occasionally  occur  as  the  result  of  irritating  chemical  solutions 
used  as  bladder  irrigations.  Foreign  bodies  when  left  in  the  bladder  may  cause  a 
mechanical  inflammation.  The  disease  is  caused  in  nearly  all  cases  by  the  action 
of  bacteria.  These  are  generally  introduced  in  the  act  of  catheterization,  but  may 
invade  the  bladder  also  from  neighboring  abscesses,  from  inflammatory  exudates, 
through  fistulas  (suprapubic,  vesicovaginal,  rectovesical,  etc.),  or  from  an  infected 
kidney  or  ureter.  The  microorganisms,  at  times,  gain  entrance  through  the  blood- 
vessels or  lymph-vessels,  by  direct  invasion  from  the  intestinal  tract,  or  through 
the  urethra.  In  certain  cases  the  mere  introduction  of  bacteria  seems  to  be  all 
that  is  necessary  to  cause  the  cystitis.  Nearly  all  investigators,  however,  are  agreed 
that  there  are  certain  conditions  which  predispose  to  infection  of  the  bladder. 
In  the  normal  bladder  bacteria  can  be  introduced  and  may  not  cause  a  cystitis, 
while  if  the  predisposing  conditions  are  present  the  affection  is  apt  to  result.  Any- 
thing which  prevents  the  complete  emptying  of  the  bladder — as  exudates  in  the 
adjacent  tissues,  pelvic  tumors,  cystocele,  fixation  of  the  uterus  in  malpositions,  or 
partial  paralysis  of  the  bladder  by  injury  or  overdistention — renders  this  organ 
more  liable  to  infection.  There  seems  to  be  a  special  liability  to  cystitis  following 
pan-hysterectomies  for  carcinoma  of  the  cervix  and  after  operations  where  much 
trauma  of  the  bladder  occurs.  The  other  predisposing  causes  are  congestion  of 
the  bladder,  a  wide,  patulous  urethra,  abrasion  of  the  wall  of  the  bladder  or  urethra, 
and  the  presence  of  foreign  bodies. 

The  bacteria  which  are  most  frequently  found  in  post-operative  cystitis  are  the 
Bacillus  coli  communis,  the  various  staphylococci,  the  Bacillus  proteus  vulgaris, 
and  the  Streptococcus  pyogenes. 

The  symptoms  and  diagnosis  of  cystitis  will  not  be  given  here  further  than  to 
state  that  the  condition  is  usually  not  recognized  until  the  occurrence  of  vesical  pain 
and  tenesmus.  The  frequent  examination  of  the  urine  for  a  few  weeks  after  opera- 
tion is  advisable  in  all  cases,  as  by  this  means  the  condition  can  be  recognized  in 
its  incipiency.  Any  unexpected  elevation  of  temperature  occurring  after  the  first 
five  or  six  days  following  operation  should  make  one  consider  cystitis  as  a  possible 
cause. 

^Yith  regard  to  prophylaxis  it  is  well  to  emphasize  the  necessity  of  avoiding 
injury  to  the  bladder  during  operation,  of  the  careful  arrangement  of  tampons  and 
drains,  and  the  utmost  care  in  the  use  of  specula,  catheters,  and  sounds  in  exploring 
the  bladder  when  the  patient  is  anesthetized.  If  the  use  of  a  retention  catheter  be 
necessary,  great  care  should  be  exercised  in  preventing  infection  in  changing  it. 


POST-OPERATIVE  COMPLICATIONS  CONNECTED  WITH  BLADDER,  KIDNEYS,  ETC.    45 

and  in  the  selection  of  one  which  will  cause  no  abrasion  of  the  mucosa  of  the  blad- 
der or  urethra.  It  is  necessary  to  see  that  it  drains  well  and  that  no  urine  returns 
from  the  receptacle,  which  should  contain  an  antiseptic  solution,  into  the  bladder. 

The  most  frequent  cause  of  cystitis  is  catheterization.  This  procedure  not  only 
introduces  bacteria,  but  frequently  produces  an  abrasion  of  the  mucosa  of  the  blad- 
der or  urethra.  The  following  suggestions  have  been  found  of  value  in  catheteriza- 
tion after  operation :  Allow  the  patient  to  go  eight  to  ten  hours  before  the  catheter 
is  used,  unless  she  suffers  considerable  pain;  encourage  her  to  void  by  placing  a 
bed-pan  under  her  and  allowing  a  stream  of  water  to  flow  over  her  genitalia;  use 
a  stream  of  some  weak  antiseptic  solution  in  cleansing  the  meatus  instead  of  cotton 
pledgets;  use  the  smallest  glass  or  soft-rubber  catheter  feasible  and  do  not  handle 
the  portion  of  the  catheter  which  is  to  be  inserted  into  the  urethra.  Following  the 
advice  of  Wertheim,  several  operators  after  the  abdominal  hysterectomy  for  cancer 
of  the  uterus,  or  after  any  operation  where  the  bladder  is  injured,  practise  irrigation 
of  the  bladder  at  each  catheterization  until  it  can  be  completely  emptied  voluntarily. 

The  use  of  the  normal  salt  solution  subcutaneously  or  into  the  peritoneal  cavity, 
by  diluting  the  urine  tends  to  act,  no  doubt,  as  a  prophylactic  measure  against  the 
occurrence  of  cystitis. 

The  treatment  of  cystitis  is  given  fully  in  another  chapter  of  this  work,  but  I 
will  detail  here  the  method  which  has  given  the  most  satisfactory  results  in  my  hands. 
As  soon  as  the  diagnosis  of  cystitis  is  made  the  patient  is  put  upon  a  bland  diet, 
urotropin  (gr.  xx)  is  given  daily,  and  the  bladder  is  irrigated  with  a  2  per  cent, 
boric  acid  solution  twice  daily.  Following  the  thorough  irrigation,  2  to  4  ounces  of 
0.5  per  cent,  protargol  solution  is  allowed  to  run  into  the  bladder  and  to  remain  fifteen 
to  twenty  minutes,  the  patient  voiding  it  at  the  end  of  this  time.  This  instillation  of 
protargol  has  given  me  really  remarkable  results  in  the  cases  where  I  have  employed 
it  in  post-operative  cystitis.  In  most  of  the  cases  pus  and  bacteria  have  disap- 
peared after  a  few  instillations  and  the  patients  were  practically  well  in  two  or  three 
days.  The  urotropin  is  continued  for  a  week  or  ten  days  longer  and  the  urine  is 
examined  daily.  If  there  is  a  return  of  the  cystitis,  the  irrigations  and  instillations 
are  repeated. 

Kidney  Complications. — During  the  administration  of  ether  there  is  a  diminu- 
tion in  the  amount  of  the  urine  which  is  secreted  and  albumin  generally  makes  its 
appearance.  Thomson  and  Kemp^  found  in  experiments  on  animals  that  there 
was  in  dogs  a  constant  decrease  in  the  amount  of  the  secretion,  and  under  free  and 
continuous  etherization  a  complete  suppression  of  urine  occurred.  Albumin  appeared 
early  even  under  moderate  anesthesia,  and  increased  in  amount  until,  just  before 
suppression  occurred,  it  amounted  to  60  per  cent,  by  volume.  Chloroform  had 
much  less  influence  upon  the  urinary  secretion,  the  urine  continuing  to  flow  until 
just  before  death  and  albumin  appearing  only  after  prolonged  anesthesia.     Kelly^ 


'  Thomson  (W.  H.)  and  Kemp  (R.  C):  "Experimental  Researches  on  the  Effects  of  Different 
Anesthetics,"  Med.  Rec,  N.  Y.,  1898,  Hv,  325-330. 

^  Kelly,  H.  A.:  "Urinalysis  in  Gynecology,"  Am.  Jour.  Obst.,  N.  Y.,  1893,  xxviii,  429. 


46  COMPLICATIONS  FOLLOWING  OPERATIONS. 

and  Noble^  called  attention  to  the  necessity  for  systematic  examination  of  urine 
prior  to  operation  and  the  danger  of  operating  upon  cases  where  chronic  nephritis 
exists.  According  to  Kelly,  Noble,  Russell,^  Ogden,^  and  others,  in  a  large  percen- 
tage of  cases  albumin  and  casts  make  their  appearance  in  the  urine  after  operations. 
Their  presence  is  not,  as  a  rule,  significant,  and  is  due  probably  to  circulatory 
changes  in  the  kidneys,  for  in  a  few  days  they  disappear  entirely.  Sugar  is  excep- 
tionally found  after  anesthesia,  and  is  likewise  of  little  significance.  The  quantity 
of  urine  is  markedly  diminished  during  the  first  few  days  after  operation,  the  amount 
being  usually  only  500  to  600  c.c.  With  the  free  ingestion  of  water  the  amount  of 
urine  is  greatly  increased.  Enteroclysis,  hypodermoclysis  (after  operation),  and 
the  giving  of  water  freely  before  operation,  greatly  increase  the  amount  of  urine 
after  operation. 

Acute  nephritis  following  gynecologic  operations  is  an  extremely  rare  affection, 
except  in  cases  of  post-operative  pneumonia,  infections,  and  ileus.  Independently 
of  these  diseases  it  is  seldom  seen.  In  7000  gynecologic  operations  at  the  Johns 
Hopkins  Hospital  I  could  find  only  two  such  cases  where  the  symptoms  of  neph- 
ritis were  marked.  Its  causes  are  cold,  the  use  of  turpentine  or  carbolic  acid, 
infections,  and  to  a  certain  extent,  perhaps,  the  action  of  the  anesthetic.  Acute 
nephritis  frequently  accompanies  intestinal  obstruction,  and  is,  at  times,  hemor- 
rhagic in  character.  Noble  disagrees  with  this  statement  and  considers  post-opera- 
tive nephritis  as  indicated  by  the  presence  of  casts  and  albumin  in  the  urine,  with 
diminished  secretion,  as  being  quite  common,  and  easily  curable,  as  a  rule. 

The  symptoms  vary  considerably  and  the  diagnosis  can  in  many  cases  be  obscure. 
In  one  of  our  cases  there  was  no  edema.  The  nephritis  followed  a  suspension  of 
the  uterus  and  perineorrhaphy  and  the  symptoms  were  as  follows:  Temperature 
of  102°  to  103°  F.,  convulsions,  headache,  defective  eyesight,  anemia,  and  nausea. 
The  urine  contained  a  large  amount  of  albumin  and  a  large  number  of  hyaline  and 
granular  casts.  She  eventually  recovered.  In  the  other  case  the  nephritis  was 
accompanied  by  mania.  Although  acute  nephritis  arising  in  previously  healthy 
kidneys  rarely  occurs  after  gynecologic  operations,  chronic  nephritis  frequently 
exists  at  the  time  of  operation  and  has  a  marked  influence  upon  the  extent  of  opera- 
tive procedure,  the  prognosis,  and  the  after-treatment. 

Suppression  of  Urine. — As  has  been  previously  noted,  for  the  first  few  days 
after  operation  there  is  a  marked  diminution  in  the  amount  of  urine  secreted. 
This  is  due  to  the  recumbent  position,  the  diminished  ingestion  of  fluids,  the  loss 
of  blood,  perhaps  the  action  of  the  anesthetic,  fever,  and  congestion  of  the  kidney. 
In  some  cases,  however,  the  amounts  of  urine  and  urea  remain  so  small  that  we  look 
for  some  cause  of  the  diminution  or  suppression. 

The  chief  causes  of  urinary  suppression  are  as  follows:  Nephritis;    blocking 

^  Noble,  C.  P  :  "The  Relation  of  Certain  Urinary  Conditions  to  Gynecological  Surgery,"  Am. 
Jour.  Obst.,  N.  Y.,  1893,  xxviii,  753-762. 

*  Russell,  W.  W.:    "Urinalysis  in  Gynecology,"  Johns  Hopkins  Hosp.  Rep.,  iii,  433. 

2  Ogden,  J.  B.:  "Effects  of  Ether  on  the  Kidneys,"  Jour.  Bost.  See.  Med.  Sc,  1897,  No.  15, 
18-23. 


POST-OPERATIVE  COMPLICATIONS  CONNECTED  WITH  BLADDER,  KIDNEYS,  ETC.    47 

of  one  ureter,  or  serious  injury  to  one  kidney  with  coexisting  disease  of  the  other; 
the  hgation  or  clamping  of  one  or  both  ureters;  removal  of  the  only  kidney;  obstruc- 
tion of  the  bowels;  and  collapse  after  severe  operations. 

In  our  7000  cases  the  ureter  is  known  to  have  been  accidentally  ligated  or  clamped 
fifteen  times.  In  twelve  of  these  cases  the  ligation  or  clamping  was  discovered 
before  the  patient  left  the  operating  table  and  the  error  remedied.  In  one  case  of 
vaginal  hysterectomy  for  carcinoma  of  the  cervix,  the  ureter  containing  a  bougie 
was  clamped  and  the  bougie  broken  off,  a  portion  of  it  being  left  in  the  ureter.  The 
condition  of  the  patient  prevented  any  operative  procedure  for  its  removal.  Her 
death  on  the  seventh  day  after  operation  was  probably  due  in  part  to  the  accident. 
In  another  case  where  the  catheterized  ureter  was  clamped  and  the  clamp  removed 
the  ureter  was  so  injured  that  a  ureterovaginal  fistula  resulted,  but  healed  in  a  few 
weeks  without  operative  procedure.  In  the  remaining  ten  cases  no  untoward 
results  are  known  to  have  arisen,  although  in  one  instance  the  ureter  was  twice 
ligated  and  once  clamped.  Of  the  three  cases  in  which  the  accident  was  not  dis- 
covered, two  died  and  one  developed  a  ureterovaginal  fistula.  In  another  case 
almost  total  suppression  of  urine  occurred  after  the  removal  of  a  large  calculus 
from  one  kidney  when  the  other  was  almost  totally  destroyed  by  a  second  stone. 
The  largest  number  of  cases  of  urinary  suppression  probably  occurs  in  patients 
where  one  kidney  is  removed  when  the  other  kidney  is  likewise  diseased.  The 
greatest  care  should  always  be  exercised  to  ascertain  the  exact  condition  of  both 
kidneys  before  the  removal  of  either.  This  can  be  done  only  by  the  examination 
of  the  separated  urines;  palpation  and  inspection  of  the  kidney  being  valuable  aids. 
Without  the  urinary  examination  the  latter  are  not  to  be  depended  upon.  The  neces- 
sity of  repeated  and  careful  urinary  examinations  is  to  be  emphasized  in  operations 
for  incarcerated  fibromyomata  or  other  conditions  where  the  kidneys  are  apt  to  be 
affected  from  pressure  upon  the  ureters.  In  one  of  my  cases  where  after  a  difficult 
hysteromyomectomy  the  patient  died  from  urinary  suppression,  there  was  found  at 
autopsy  one  atrophied  kidney  and  an  acute  nephritis  in  the  remaining  organ.  Two 
cases  of  complete  suppression  due  to  obstruction  in  the  small  intestine  have  come 
under  my  observation.  Suppression  of  urine  in  previously  healthy  kidneys  as  a 
direct  result  of  the  anesthetic  or  collapse  is  rare  as  a  post-operative  complication. 

The  diagnosis  of  the  cause  of  the  suppression  is  very  important,  especially  if  there 
is  a  possibility  of  occlusion  of  the  ureter.  The  diagnosis  of  occlusion  of  the  ureter 
is  usually  very  difficult  to  make,  there  undoubtedly  being  women  in  whom  one 
ureter  is  occluded  at  operation  and  no  symptoms  arise  during  the  convalescence 
to  indicate  its  occurrence,  or  in  whom  the  symptoms  are  confounded  with  those 
which  so  frequently  follow  serious  laparotomies.  The  important  points  in  making 
a  diagnosis  of  the  condition  are :  (a)  pain  along  the  course  of  the  ureter  and  in  the 
region  of  the  kidney,  (6)  the  nature  of  the  operation  and  the  probability  of  the 
occurrence  of  the  accident,  and  (c)  complete  suppression  of  urine  or  marked  dimi- 
nution in  the  amount  passed.  The  last  sign  is  of  little  importance  unless  found  in 
combination  with  at  least  one  of  the  others.     In  cases  where  there  is  a  strong  prob- 


48  COMPLICATIONS    FOLLOWING    OPERATIONS. 

ability  of  the  accident  having  occurred  the  ureters  should  be  catheterized  if  the 
condition  of  the  patient  warrants  such  a  procedure. 

The  treatment  depends  largely  upon  the  cause.  When  the  ureter  is  obstructed 
the  obstruction  should  be  removed  just  as  soon  as  a  diagnosis  can  be  made.  In 
ileus,  operative  procedure  for  its  relief  is  usually  too  late  after  suppression  occurs, 
although  it  should  be  tried.  In  all  cases  where  there  is  no  obstruction  of  the  ureter 
the  treatment  consists  in  cupping  the  loins,  hot  applications,  free  purging,  and 
sweating  with  the  vapor  bath  or  with  pilocarpin.  It  should  not  be  forgotten  that 
pilocarpin  is  a  treacherous  drug  and  likely  to  cause  edema  of  the  lungs.  Diuretin  is 
recommended  after  the  secretion  has  started.  Irrigation  of  the  rectum  with  hot  salt 
solution  by  means  of  a  two-way  tube  is  likewise  recommended.  The  method  of 
Murphy  of  permitting  salt  solution  to  run  into  the  rectum  drop  by  drop,  averaging 
a  quart  every  two  or  three  hours,  is  to  be  commended  highly.  Enemata  and  sub- 
cutaneous injections  of  salt  solution  are  very  useful.  The  treatment  of  nephritis 
as  a  post-operative  affection  differs  only  from  that  usually  laid  down  in  so  far  as 
it  is  modified  by  the  wound  and  other  conditions  pertaining  to  the  operation. 

Blood-clots. — Occasionally  after  operations  upon  the  kidney  or  bladder  free 
hemorrhage  occurs  and  the  blood  clotting  in  the  bladder  acts  as  a  foreign  body. 
An  almost  complete  cast  of  the  bladder  may  be  produced  by  the  blood-clot.  Un- 
less these  clots  are  removed  they  will  give  rise  to  pain  and  discomfort,  or,  becoming 
infected,  may  cause  cystitis  or  an  ascending  infection  of  the  kidneys.  The  condi- 
tion may  be  diagnosed  by  the  continued  presence  of  blood  in  the  urine,  frequent 
and  painful  micturition,  and  by  palpation.  By  means  of  the  latter  the  clot  of  large 
size  can  generally  be  detected. 

The  treatment  consists  primarily  in  checking  the  hemorrhage,  and  secondarily 
in  removing  the  clots.  If  the  hemorrhage  comes  from  a  vessel  in  the  bladder  wall 
after  the  closure  of  a  fistula  it  is  better  to  cut  the  sutures,  find  the  vessel,  ligate  it, 
and  resuture.  Where  the  hemorrhage  comes  from  the  kidney  and  the  blood  coagu- 
lates in  the  bladder,  it  generally  suffices  for  its  removal  to  irrigate  the  bladder 
frequently  with  the  normal  saline  solution  until  all  of  the  clots  have  been  dissolved. 
It  may  be  necessary  to  open  the  bladder  through  the  vagina  to  turn  out  the  clots, 
but  this,  as  a  rule,  is  unnecessary. 

Pyelitis — Pyonephrosis. — Inflammation  of  the  pelvis  of  the  kidney  and  the 
conditions  which  result  from  it  may  follow  operation  and  be  due  to  various  causes. 
It  is,  however,  most  frequently  seen,  when  occurring  as  a  post -operative  complica- 
tion, in  those  cases  in  which  the  kidney,  ureter,  or  bladder  has  been  operated  upon, 
accidentally  injured,  or  is  involved  in  inflammatory  exudates,  or  as  consecutive  to 
cystitis.  Cases  of  implantation  of  the  ureters  into  the  intestine  are  almost  invariably 
followed  by  an  ascending  infection  of  the  kidney.  Ureteral  fistulas  emptying  into 
the  vagina  or  on  the  skin  are  apt  sooner  or  later  to  lead  to  a  pyelitis.  In  like  manner 
there  is  considerable  danger  of  the  infection  extending  from  a  cystitis  to  the  kidney 
along  the  ureter.  Pyelitis  following  cystitis  is  usually  bilateral.  In  cases  of  infec- 
tion of  the  kidney  pelvis  the  process  is  liable  to  extend  by  way  of  the  tubules  or 


POST-OPERATIVE  COMPLICATIOXS  CONNECTED  WITH  BLADDER,  KIDNEYS,  ETC.    49 

lymphatics  to  the  kidney  substance,  causing  acute  suppurative  nephritis.  The 
latter  condition  may  arise  in  the  manner  just  indicated  or  it  may  be  a  part  of  an 
infection  coming  from  other  portions  of  the  body  through  the  blood-channels  or 
lymph-channels.  After  operation  upon  the  pelvic  organs  many  conditions  favor- 
able to  the  development  of  a  pyelitis  may  be  present ;  namely,  there  may  be  pressure 
upon  the  ureter  by  exudates,  ligatures,  packs,  or  scar  tissue  in  the  bladder  or  along 
the  course  of  the  ureter,  causing  a  blocking  of  the  ureter  and  a  dilatation  of  the 
ureter  and  pelvis  of  the  kidney ;  there  may  be  suppuration  in  the  immediate  vicinity 
of  the  ureter;  the  vitality  of  the  patient  is  lowered  by  the  primary  disease  and  the 
operation  through  which  she  has  been,  and  cystitis  is  not  infrequently  present  to 
act  as  a  starting-point  for  the  infection.  The  infection  at  times  reaches  the  kidney 
through  the  blood,  and  not  as  an  ascending  ureteritis. 

The  symptoms  are  as  follows :  ( 1 )  Pyuria.  The  urine  contains  pus  and  bacteria. 
When  only  one  kidney  is  involved,  the  amount  of  pus  in  the  urine  may  vary,  due 
to  the  temporary  blocking  of  the  ureter  on  the  affected  side.  The  bladder  is  usually 
involved  and  consequently  there  may  be  painful  and  frequent  micturition.  (2) 
Fever  of  an  intermittent  type  associated  with  chills  is  usually  present.  (3)  Pain  in 
the  region  of  the  kidney  may  be  present  and  occasionally  an  attack  resembling 
renal  colic  is  seen.  (4)  The  general  condition  of  the  patient  indicates  suppuration 
and,  at  times,  loss  of  kidney  function.  (5)  Physical  examination  may  reveal  ten- 
derness over  the  kidney  and,  at  times,  an  enlargement  of  the  organ.  (6)  Examina- 
tion of  the  bladder  and  observation  of  the  urine  as  it  comes  from  the  ureter,  or  its 
collection  by  means  of  the  ureteral  catheter,  is  quite  feasible  in  most  cases,  and  is  of 
the  greatest  value  in  the  determination  of  the  diagnosis,  prognosis,  and  treatment. 

The  diagnosis  is  of  the  utmost  importance,  as  it  may  save  the  patient  from  use- 
less operative  procedure,  dosing  for  malaria,  etc.,  and  indicate  at  least  some 
rational  method  of  treatment.  It  is  likewise  very  important  to  know  if  one  or  both 
kidneys  are  infected  and  the  working  value  of  each.  This  can  be  done  by  the  use  of 
the  ureteral  catheter  in  collecting  the  urine  from  the  infected  kidney,  and  in  examin- 
ing this  urine  and  that  from  the  bladder  with  regard  to  specific  gravity,  amount  of  pus, 
color,  reaction,  and  amount  of  urea.  I  will  illustrate  by  an  example :  The  specimen 
obtained  from  the  ureter  from  which  purulent  urine  was  seen  to  flow  is  found  to 
have  a  low  specific  gravity,  considerable  amount  of  albumin,  much  pus,  and  very 
little  urea.  The  bladder  urine  has  a  higher  specific  gravity,  less  pus  and  albumin, 
and  more  urea.  Now  the  inevitable  conclusion  must  be  that  the  other  kidney  is 
doing  more  work  than  the  infected  one.  If,  in  addition  to  this,  some  urine  can  be 
collected  from  the  supposedly  healthy  kidney  without  running  any  risk  of  infect- 
ing it,  and  this  proves  to  be  normal,  the  feasibility  of  remo\ang  or  draining  the 
infected  kidney  can  be  considered.  The  subject  of  kidney  infection  is  treated  more 
fully  in  diseases  of  the  urinary  tract,  but  the  necessity  of  recognizing  the  disease 
as  a  complication  of  operation  is  so  important  that  a  notice  of  it  here  was  not  con- 
sidered out  of  place. 

Hydronephrosis  or  dilatation  of  the  pelvis  and  calyces  of  the  kidney  by  the  accu- 

VOL.  II 4 


50  COMPLICATIONS   FOLLOWING    OPERATIONS. 

mulation  of  non-purulent  urine,  may  likewise  occur  as  a  post-operative  complication. 
Hydro-ureter  usually  accompanies  the  post-operative  variety  of  hydronephrosis. 

The  causes  of  post-operative  hydronephrosis  are  conditions  arising  during  or 
after  operation  which  cause  blocking  of  the  ureter.  This  blocking  is  usually  not 
complete,  as,  when  no  urine  passes  along  the  ureter,  atrophy  of  the  kidney  is  said 
to  result.  The  interference  with  the  lumen  of  the  ureter  may  be  due  to  ligation 
or  injury  of  the  ureter;  fixing  the  kidney  in  malposition;  or  twisting,  kinking,  or 
compression  of  the  ureter  at  the  time  of  the  operation.  After  operation  adhesions, 
exudates,  scar  tissue,  tampons,  and  over-distention  of  the  bladder  may  act  as  causes 
of  hydronephrosis.  In  many  cases  there  is  at  first  a  hydronephrosis,  which  later 
becomes  infected,  forming  a  pyonephrosis. 

The  symptoms  of  the  affection  are  usually  as  follows:  (1)  Pain  in  the  region 
of  the  kidney  and  along  the  course  of  the  ureter.  (2)  Diminution  for  a  short  but 
varying  period  of  time  of  the  amount  of  the  urine  passed.  (3)  The  presence  of  a 
tumor  in  the  region  of  the  kidney,  which  is  usually  tender.  (4)  Uremic  symptoms 
may  be  present. 

The  catheterization  of  the  ureters  will  show  whether  or  not  the  ureter  is  blocked. 

The  indications  for  treatment  are  to  remove,  if  possible,  the  cause  of  the  con- 
striction of  the  ureter,  and  to  supplement  the  work  of  the  kidney  by  purgation, 
diaphoresis,  etc.  In  a  number  of  cases  of  post-operative  hydronephrosis  and  pyone- 
phrosis, nephrotomy  or  nephrectomy  is  indicated. 

Fistulas. — Fistulas  following  operations  upon  the  urinary  tract  are  of  tolerably 
frequent  occurrence  and  can  be  conveniently  divided  into  renal  and  circumrenal, 
ureteral,  and  vesical. 

Renal  and  Circumrenal  Fistulas. — Following  nephrectomy,  nephrotomy, 
nephropexy,  and  other  operations  upon  the  kidney,  a  fistula  may  form.  This  may 
not  communicate  with  the  pelvis  of  the  kidney  nor  with  the  urinary  tract  at  any 
point,  and  in  this  case  no  urine  escapes  from  the  fistulous  opening.  Should  the 
fistula  lead  down  to  the  pelvis  of  the  kidney  or  ureter,  urine  will  usually  be  found 
to  escape  along  the  tract.  Nephrotomy  for  hydronephrosis,  calculus,  suppurative 
nephritis,  or  tuberculosis  of  the  kidney  is  liable  to  be  followed  by  a  fistula  which 
frequently  does  not  heal  until  the  kidney  is  removed. 

Morris^  gives  the  following  table  to  illustrate  the  frequency  with  which  fistula 

follows  operations  on  the  kidney: 

Nepholithotomy 33  operations.  Fistula  in  5  cases. 

Nephrotomy  for  calculus 32           "  Fistula  in  10      " 

Nephrectomy  for  calculus 12           "  Fistula  in  2      " 

Nephrectomy  for  acute  suppuration 1  operation.  Fistula  in  0      " 

Exploration  of  kidney 42  operations.  Fistula  in  1  case. 

Operations  for  nephropexy 57           "  Fistula  in  7  cases. 

Operations   for   hydronephrosis    and   pyone- 
phrosis   16          "  Fistula  in  2      " 

Operations  upon  tuberculous  kidneys 21           "  Fistula  in  3      " 

Operations  upon  tumors  of  kidneys 11           "  Fistula  in  0      " 

Operations  for  injury  of  kidneys 4          "  Fistula  in  2      " 

229  32 

1  Morris,  H.:  "Surgical  Diseases  of  the  Kidney  and  Ureter,"  1901,  i,  378. 


POST-OPERATIVE  COMPLICATIONS  CONNECTED  WITH  BLADDER,  KIDNEYS,  ETC.    51 

Where  a  suppurative  process  is  going  on  in  the  kidney;  where  there  is  tu- 
berculosis, either  renal  or  circumrenal ;  where  there  is  an  obstruction  to  the  pas- 
sage of  the  urine  along  the  ureter;  or  where  foreign  bodies,  such  as  a  calculus 
or  a  non-absorbable  suture,  are  present,  the  tendency  for  the  fistula  to  remain 
open  is  much  greater  than  in  other  cases.  In  Morris'  cases  the  majority  finally 
closed. 

These  fistulas  nearly  all  open  externally  and  very  little  difficulty  is  experienced 
in  determining  their  nature.  Rarely  in  nephrectomy  is  an  opening  made  into  the 
duodenum  or  colon,  and  a  fistulous  tract  leading  into  the  gut  may  persist.  A  case 
occurred  in  the  gynecologic  service  of  the  Johns  Hopkins  Hospital  in  which  two 
fistulas  communicating  with  the  duodenum  followed  the  removal  of  a  densely 
adherent  kidney.  Renal  fistula  communicating  with  the  stomach  or  portions  of  the 
alimentary  tract  other  than  the  duodenum  or  colon,  or  opening  into  the  lung,  have 
been  reported,  but  these  were  not  post-operative  in  character. 

Treatment. — After  the  formation  of  the  fistula  it  should  be  kept  clean  by  irriga- 
tions and  frequent  changing  of  the  dressings.  Injections  of  stimulating  solutions, 
cauterization,  etc.,  may  be  tried  after  the  fistula  has  become  chronic.  If  it  shows 
no  tendency  to  heal  after  several  months,  an  operation,  thoroughly  exploring  the 
fistulous  tract,  should  be  done,  and  foreign  bodies,  as  sutures  and  calculi,  removed. 
In  case  the  kidney  is  tuberculous  or  badly  diseased  and  the  other  one  is  healthy,  a 
nephrectomy  is  advisable.  If  the  persistence  of  the  fistula  is  due  to  the  blocking 
of  the  ureter  by  a  calculus  or  stricture  or  other  cause,  this  should  be  remedied  by 
the  operative  procedure,  and  where  tuberculosis  of  the  ureter  is  the  cause  of  the 
persistence  of  the  fistula  ureterectomy  is  advisable. 

Ureteral  Fistulas. — Post-operative  ureteral  fistulas  are  generally  due  to  trau- 
matism of  the  ureter  during  operation,  or  to  sloughing  of  this  structure  produced  by 
interference  with  its  blood-supply  in  the  extensive  dissections  now  practised  in 
operations  for  carcinoma  of  the  cervix,  or  by  pressure  of  clamps,  drainage-tubes, 
ligatures,  etc.  The  point  where  the  injury  to  the  ureter  occurs  being  in  by  far  the 
greatest  number  of  cases  in  the  pelvis,  we  commonly  see  ureterovaginal  fistulas. 
The  fistula  may,  however,  open  into  the  abdominal  wound,  into  the  bladder,  or 
into  the  intestine.  In  case  no  provision  is  made  for  the  escape  into  the  urine  exter- 
nally at  the  time  of  operation,  it  finds  its  way  into  the  peritoneal  cavity  or  infiltrates 
the  tissues  of  the  pelvis  or  abdominal  walls. 

Where  the  urine  escapes  through  the  vagina  or  along  the  drainage  tract  in  the 
abdominal  wound  the  diagnosis  of  urinary  fistula  is  self-evident.  The  differential 
diagnosis  between  ureteral  and  vesical  fistula  is  given  in  the  chapter  devoted  to 
this  subject. 

The  occurrence  of  a  ureteral  fistula  where  there  is  free  escape  of  urine  does  not, 
as  a  rule,  interfere  to  a  marked  extent  with  the  recovery  of  the  patient  from  the 
primary  operation.  Death  is  the  usual  result  when  there  is  infiltration  of  the  tissue 
with  urine  or  an  escape  of  it  into  the  general  peritoneal  cavity. 

The  indication  for  immediate  treatment  is  to  provide  for  a  free  escape  of  the  urine. 


52  COMPLICATIONS    FOLLOWING    OPERATIONS. 

and  by  frequent  cleansing,  douching,  and  irrigation  to  keep  the  wound  and  sur- 
rounding tissue  from  becoming  foul  and  irritated. 

Vesical  Fistulas. — The  causes  of  post-operative  vesical  fistulas  are  practically 
those  of  ureteral  fistulas.  The  bladder  may  be  opened  accidentally  or  intention- 
ally at  the  operation  and  the  opening  either  not  discovered  or  the  sutures  used  in 
repairing  the  injury  may  not  hold.  Pressure  by  clamps,  tampons,  drainage-tubes, 
and  ligatures,  or  injuries  by  the  cautery  may  cause  sloughing  of  the  vesical  wall,  or 
the  base  of  the  bladder  may  be  involved  by  an  extension  of  the  carcinoma  from  the 
cervix.  An  abscess  may  communicate  with  the  bladder  and  after  its  removal  a 
fistula  may  appear. 

Post-operative  vesical  fistulas,  unless  due  to  carcinoma  or  tuberculosis,  tend  to 
heal  spontaneously.  The  operative  procedure  for  closing  these  fistulas  is  given 
elsewhere  in  this  work. 

PRESSURE   PARALYSIS. 

In  laparotomies  when  the  patient's  arms  are  extended  above  her  head,  or  in 
extension  of  the  arm  in  breast  operations,  the  brachial  plexus  of  nerves  is  occasionally 
pressed  upon  so  forcibly  as  to  cause  paralysis  of  the  arm.  Paralysis  due  to  pressure 
on  the  musculospiral  nerve  may  occur  when  an  arm  hangs  over  the  edge  of  the 
table  while  the  patient  is  unconscious.  Cases  of  paralysis  of  the  muscles  of  the  leg 
by  pressure  of  a  leg-holder  where  the  lithotomy  position  was  used  have  likewise  been 
reported.  Paralysis  also  may  occur  from  the  pressure  of  the  shoulder  supports 
when  the  patient  is  in  the  Trendelenburg  position. 

The  symptoms  vary  in  the  individual  cases  from  slight  tingling  along  the  course 
of  the  nerve,  some  loss  of  sensation  and  muscular  power  for  a  few  hours,  to  more  or 
less  complete  motor  paralysis,  marked  anesthesia,  neuritis,  and  trophic  changes 
lasting  for  weeks  or  months. 

This  annoying  accident  is  to  be  avoided  by  the  use  of  proper  position  of  the  arm 
during  anesthesia  and  care  that  no  undue  pressure  is  made  on  the  nerves.  The 
arms  should  be  folded  across  the  chest  during  laparotomies  and  in  breast  operations 
•  should  not  be  unduly  extended.  When  the  Trendelenburg  position  is  employed, 
broad  and  padded  shoulder-rests  should  be  used,  as  pressure  palsy  may  be  caused 
by  the  weight  of  the  body  pressing  against  the  shoulder-rests.  In  the  use  of  the 
leg-holder  one  should  see  that  the  limbs  are  not  unduly  constricted.  The  treatment 
of  the  paralysis  consists  in  the  application  of  massage  and  electricity  to  the  affected 
limb  and  the  internal  use  of  strychnin. 

Quite  frequently  following  operations  in  which  the  sensory  nerves  are  cut  or 
injured,  as  in  nephrectomies,  nephrotomies,  appendicectomies,  herniotomies,  etc., 
areas  of  anesthesia  follow.  These  may  persist  for  quite  a  long  time,  but  are  not 
serious  in  their  nature  and  give  rise  to  little  or  no  inconvenience.  The  sensation,  as  a 
rule,  gradually  returns.  In  like  manner  the  motor  nerves  may  be  injured  or  excised, 
especially  in  operations  on  the  kidney,  and  paralysis  of  the  muscles  supplied  by 
the  nerves  follows.     The  muscles  of  the  abdomen,  being  supplied  by  numerous 


BURNS.       SEPARATION    OF   ABDOMINAL   INCISION.  53 

nerves,  suffer  comparatively  little  by  the  loss  of  function  of  one  or  more  of  them. 
Loss  of  symmetry  of  the  abdomen  and  atrophy  of  the  abdominal  wall  may,  however, 
develop  subsequently.  Incisions  made  in  the  median  line  of  the  abdomen  are 
never  complicated  by  these  accidents. 

In  making  his  incision  where  there  is  a  liability  to  injure  the  nerve  the  surgeon 
should  be  careful  not  to  sever,  seriously  lacerate,  or  include  it  in  his  ligatures.  At 
times  it  is  better  deliberately  to  sever  the  nerve  and  suture  it  at  the  end  of  the  opera- 
tion. In  other  cases  it  may  be  necessary  to  leave  the  ends  apart  or  deliberately  to 
excise  a  portion  of  the  nerve.  If  serious  inconvenience  results  from  the  loss  of 
nerve-supply,  the  separated  ends  can,  at  times,  be  dissected  out  subsequently  and 
sutured. 

BURNS. 

Patients  who  have  lost  a  large  amount  of  blood  are  very  susceptible  to  the  effects 
of  heat.  Ugly  burns  are  occasionally  caused  by  the  application  of  hot-water  bags 
and  bottles  to  the  skin  of  the  patient  in  cases  of  hemorrhage  and  shock  before  she 
has  regained  consciousness  ofter  operation.  Discredit  attaches  itself  to  the  hospital, 
surgeon,  and  nurse,  and  suits  for  damages  are  apt  to  follow.  The  liability  of  the 
occurrence  of  this  accident  should  be  constantly  borne  in  mind.  It  can  be  prevented 
by  having  a  few  thicknesses  of  flannel  between  the  skin  of  the  patient  and  the  hot- 
water  bag  and  by  systematically  testing  the  temperature  of  the  water  with  a  ther- 
mometer. It  is  a  good  rule  to  require  that  hot-water  bags  should  be  placed  outside 
the  blanket  when  a  patient  is  unconscious. 


SEPARATION   OF   ABDOMINAL   INCISION. 

Post-operative  hernia  frequently  follows  celiotomies  in  which  drainage  has  been 
used,  or  where  there  has  been  deep  and  extensive  suppuration  of  the  wound.  It  is, 
however,  a  late  sequela,  and  as  hernia  in  general  is  treated  in  another  chapter  it 
will  not  be  dwelt  upon  here.  There  is  a  complication  which  occasionally  takes 
place  immediately  after  operation,  which  is  not  usually  treated  under  the  head  of 
hernia,  but  which  also  depends  upon  the  giving  way  of  the  incision.  This  is  separa- 
tion of  the  edges  of  the  incision  before  firm  union  has  taken  place.  This  accident 
occurs  oftener  than  is  reported,  I  having  personal  knowledge  of  ten  or  more  cases. 
Madelung  has  reported  13  cases  and  has  collected  144  others  from  the  literature  in 
which  there  was  a  separation  of  the  wound.  It  is,  at  times,  the  result  of  suppura- 
tion in  the  line  of  the  incision,  accompanied  by  violent  muscular  efforts  in  the  acts 
of  vomiting,  coughing,  etc.  More  often,  apparently,  it  occurs  within  seventy-two 
hours  after  operation  as  a  result  of  the  muscular  efforts  mentioned  above,  and  is 
then  due  to  the  untying  or  breaking  of  the  sutures.  Distention  is  also  a  factor. 
The  accident  is  more  apt  to  occur  where  catgut  or  kangaroo  tendon  sutures  are 
used  in  closing  the  wound.  These  sutures  when  prepared  by  the  usual  methods 
lose  their  strength  in  five  or  six  days,  and  if  suppuration  has  occurred  between  the 


54  COMPLICATIONS   FOLLOWING    OPERATIONS. 

approximated  muscles  and  fasciae  the  contiguous  parts  can  be  readily  separated. 
It  occasionally  occurs  where  silver  wire  is  employed,  three  cases  of  the  kind  being 
known  to  me.  When  the  through-and-through  silkworm-gut  or  silk  sutures  are 
used  the  accident  is  less  liable  to  take  place.  In  one  case  three  through-and- 
through  silkworm-gut  sutures  were  broken  by  straining  effort  on  the  fourth  day 
and  eventration  resulted.  Catgut  sutures  are  liable  to  become  untied  and  thus 
allow  an  early  separation  of  the  sides  of  the  wound.  In  the  cases  where  silver  wire 
was  used  the  sutures  became  untwisted. 

Jahreiss^  reports  a  case  of  separation  of  the  sides  of  the  laparotomy  wound 
which  occurred  upon  the  ninth  day  after  operation  and  six  hours  after  the  removal 
of  the  interrupted  silk  sutures.  There  was  no  suppuration  of  the  wound.  The 
patient  was  badly  nourished,  had  icterus,  and  could  take  little  nourishment.  Jah- 
reiss  thought  trophic  disturbances  the  cause  of  the  separation  of  the  incision.  He 
quotes  a  case  of  Mittermaier  in  which  the  wound  probably  burst  open  upon  the 
third  day  after  operation.  It  was  discovered  ten  days  after  the  accident.  In  this 
case  catgut  sutures  alone  were  used. 

Brettauer^  reports  three  cases.  In  one  case  buried  silk  sutures  were  used  to 
close  the  muscles  and  fascia  and  catgut  to  approximate  the  peritoneum  and  skin. 
The  condition  was  discovered  seven  days  after  operation.  In  another  case  buried 
silkworm-gut  sutures  were  used  throughout  and  the  wound  was  found  open  six 
days  after  operation.  This  patient  died.  In  the  cases  coming  under  my  own  obser- 
vation in  the  majority  the  accident  happened  within  forty-eight  hours  after  operation. 
Madelung  thinks  that  the  critical  days  are  the  eighth  and  ninth  after  operation. 

Syphilis,  cachexia,  diabetes,  and  other  constitutional  conditions  are  considered 
as  predisposing  causes  in  the  cases  where  the  accident  occurs  late. 

Its  occurrence  is  accompanied  by  pain  and  symptoms  of  shock,  and  attention 
is  usually  directed  to  it  by  the  staining  of  the  dressings  after  a  fit  of  coughing  or 
vomiting.  The  coils  of  the  intestines  may  protrude  only  slightly  into  the  gaping 
wound  or  may  be  forced  entirely  outside  of  the  wound  and  lie  just  beneath  the  dress- 
ings on  the  abdominal  wall.  If  the  accident  is  not  immediately  discovered  and 
remedied,  adhesions  form  and  the  symptoms  of  intestinal  obstruction  are  apt  to 
arise.  If  suppuration  has  taken  place  in  the  incision,  a  fatal  general  peritonitis  is 
almost  certain  to  follow  the  occurrence  of  the  separation.  Fortunately  in  cases  of 
suppuration  deep  in  the  wound,  adhesions  form  between  the  intestines  or  omentum 
and  the  abdominal  wall,  and  in  a  large  majority  of  such  cases  prevent  a  wide  separa- 
tion of  the  incision,  the  protrusion  of  the  gut,  or  a  general  peritonitis. 

The  treatment  of  the  cases  where  there  is  no  suppuration  is  to  freshen  the  edges 
of  the  wound  and  to  resuture  it  after  replacing  the  protruding  viscera.  If  the 
wound  is  infected  and  adhesions  have  shut  off  the  general  peritoneal  cavity,  the 

^  Jahreiss:  "Ein  Fall  von  Platzen  der  Bauchwande  nach  Laparotomie,"  Centralbl.  f.  Gynak., 
Leipz.,  1896,  xx,  944-946. 

^  Brettauer,  J.:  "Three  Cases  of  Rupture  of  the  Abdominal  Wound  after  Celiotomy,"  Am. 
Gynec.  and  Obst.  Jour.,  N.  Y.,  1899,  xiv,  324-332. 


SLOUGHING    OF   THE    ABDOMINAL   WALL.       ENEMATA.  55 

treatment  is  to  pack  with  gauze  and  partially  approximate  the  edges  of  the  incision 
with  adhesive  straps,  allowing  the  wound  to  heal  by  granulation.  If  intestinal  ob- 
struction occurs  the  condition  is  dealt  with  according  to  the  principles  given  under 
that  heading.  It  is  inadvisable  in  the  presence  of  pus  to  reopen  the  peritoneal 
cavity  in  the  immediate  vicinity  of  the  wound.  In  such  cases  an  artificial  anus 
can  be  made,  and  after  the  incision  has  healed  the  obstruction  can  be  dealt  with  by 
a  second  operation.  In  clean  cases  the  adhesions  should  be  separated  when  the 
wound  is  closed. 

SLOUGHING  OF   THE   ABDOMINAL  WALL. 

In  a  case  coming  under  my  observation  it  became  necessary  to  reopen  the  abdo- 
men a  few  days  after  a  laparotomy  which  had  been  performed  for  pelvic  inflamma- 
tion. The  cause  of  the  second  operation  was  an  intestinal  obstruction.  The 
abdominal  walls  were  extremely  thick  and  fat.  On  account  of  signs  of  suppuration 
in  the  first  incision  it  was  deemed  advisable  to  make  the  second  3  or  4  inches  to 
one  side  of  it.  The  whole  of  the  skin  and  fat  between  the  two  incisions  sloughed 
and  the  large  raw  area  thus  formed  healed  by  granulation.  The  cause  of  the 
sloughing  was  undoubtedly  due  to  the  cutting  off  of  the  blood-supply  of  the  tissue 
which  sloughed,  by  the  incisions.  Sufficient  time  had  not  elapsed  after  the  first 
operation  to  enable  the  blood-vessels  to  form  across  the  line  of  the  first  incision  and 
supply  the  tissue  between  the  two.     The  very  fat  walls  were  a  predisposing  factor. 

This  complication  is  liable  to  occur  in  similar  cases,  although  I  have  not  been 
able  to  find  a  case  reported  in  the  journals.  If  it  becomes  necessary  after  laparot- 
omy to  make  a  second  incision,  it  should  be  made  at  a  considerable  distance  from 
the  first,  and  in  such  a  position  as  not  to  cut  the  larger  vessels  supplying  the  bridge 
of  tissue  lying  between  the  two.  It  is  better,  where  there  is  no  evidence  of  suppura- 
tion in  the  first  incision,  in  reopening  the  abdominal  cavity  to  excise  the  tissue 
which  is  immediately  adjacent  to  it.  If  the  wound  is  suppurating,  it  is,  of  course, 
necessary  to  make  the  second  opening  at  as  great  a  distance  from  it  as  is  feasible. 

EMPHYSEMA  OF   THE  ABDOMINAL  WALLS. 

Occasionally  after  a  laparotomy  where  the  incision  is  closed  in  layers  and  where 
there  is  a  loose  wrinkled  skin,  air  escapes  from  the  abdominal  cavity  into  the  con- 
nective tissue  between  the  skin  and  muscle  and  gives  rise  to  an  emphysematous 
condition  of  the  abdominal  walls.  The  condition  might  be  mistaken  for  an  infec- 
tion of  the  wound  with  the  Bacillus  aerogenes  capsulatus.  The  emphysema  may 
persist  for  a  few  weeks,  but  finally  disappears  without  causing  any  marked  incon- 
venience. 

ENEMATA. 

Occasionally  accidents  have  occurred  in  the  use  of  enemata.  After  suture  of 
the  rectum  or  sigmoid,  large  enemata  should  not  be  given.  One  has  only  to  watch 
the  distention  caused  by  allowing  0.5  to  1  liter  of  fluid  to  flow  into  the  lower  bowel 


56  COMPLICATIONS   FOLLOWING   OPERATIONS. 

to  appreciate  the  tension  put  upon  the  suture  in  such  cases.  Poisonous  solutions 
can  be  given  by  mistake,  and  in  one  case  coming  under  my  observation  the  lower 
bowel  and  skin  surrounding  the  anus  were  scalded  by  the  use  of  a  hot  enema,  the 
temperature  of  which  had  been  estimated  only  by  the  hand.  The  nozzle  of  a 
syringe  has  been  thrust  into  the  wound  instead  of  the  lumen  of  the  bowel  in  a  few 
cases  where  the  operation  was  the  restoration  of  a  ruptured  rectovaginal  septum 
or  other  operation  on  the  tissues  surrounding  the  anus.  These  accidents  are  men- 
tioned that  they  may  be  avoided. 

Irrigations,  Douches. — Cases  of  mild  post-operative  cystitis  have  been  much 
aggravated  by  the  use  of  a  strong  antiseptic  or  irritating  irrigation  of  the  bladder  by 
mistake. 

Likewise  it  occasionally  happens  that  in  giving  a  vaginal  douche  or  in  irrigat- 
ing a  drainage  tract  the  irrigating  fluid  enters  the  general  peritoneal  cavity.  This 
accident  is  liable  to  occur  when  the  irrigation  is  used  immediately  after  a  drain  or 
tampon  has  been  removed  and  before  adhesions  have  had  time  to  shut  off  the 
cavity  of  the  peritoneum,  or  when  undue  force  is  used  in  giving  the  irrigation. 
Hydrogen  peroxid  is,  owing  to  the  gas  formation,  which  takes  place  when  it  comes 
in  contact  with  pus  or  blood,  especially  Hable  to  force  its  way  into  the  abdominal 
cavity. 

The  entrance  of  the  fluid  into  the  abdominal  ca\dty  is  attended  by  severe  pain, 
the  symptoms  of  shock,  and  usually  later  by  a  rise  of  temperature.  In  most  cases 
very  little  fluid  enters  the  cavity  and  no  serious  results  follow,  but  peritonitis,  local 
or  general,  may  supervene,  or  poisoning  due  to  absorption  of  the  drug  may  ensue. 

In  clean  cases  where  little  fluid  enters  the  abdomen  it  suffices  usually  to  place 
the  patient  in  a  position  to  favor  drainage,  and  to  administer  morphin  and  stimu- 
lants. If  there  should  be  much  pus  carried  in,  or  if  a  considerable  quantity  of  a 
mercuric  chlorid  or  other  poisonous  solution  should  enter  and  not  return,  it  is 
necessary  to  open  the  abdomen  and  sponge  out  the  fluid.  When  the  solution  is 
not  a  poisonous  one,  the  chief  danger  lies  in  carrying  in  pus  and  bacteria,  and  thus 
setting  up  a  general  peritonitis.  In  such  cases  the  patient  should  be  carefully 
watched  for  forty-eight  hours,  and  if  it  should  be  apparent  that  a  peritonitis  is 
present  the  exploratory  operation  is  indicated. 


FOREIGN  BODIES  LEFT  IN  THE  ABDOMEN  AFTER  OPERATION. 

Gauzes,  sponges,  instruments,  drainage-tubes,  and  other  foreign  bodies  have 
been  left  in  the  abdominal  cavity  after  operation  and  are  a  source  of  serious  danger 
to  the  patient.  Neugebauer  has  recently^  collected  195  cases  of  the  kind.  Gauzes 
and  sponges  are  the  articles  usually  left  behind.  Such  accidents  are  most  liable 
to  occur:  in  long  and  difficult  operations;    in  conditions  where  due  deliberation 

^  V.  Neugebauer,  F.:  "87  neue  Beobachtungen  von  zufalliger  Zuriicklassung  eines  Subope- 
ratione  benutzten  Freundkorpers  (Arterien  Klemme,  Schere,  Schwamm,  Gazetupfer,  MuUkom- 
presse  usw.)  in  der  Bauchhohle  Samt  einigen  anderen  unvorhergesehen  Zufallen  intra  Opera- 
tionen,"  Zentralbl.  f.  Gynak.,  Leipz.,  1904,  iii,  66-81. 


FOREIGN  BODIES  LEFT  IN  THE  ABDOMEN  AFTER  OPERATION.        57 

cannot  be  exercised — such  as  hemorrhage,  shock,  etc. ;  and  when  there  is  difficuUy  in 
exposing  the  field  of  operation,  due  to  fat,  tympany,  straining,  etc.  In  such  cases 
many  pieces  of  gauze  and  numerous  sponges  are  needed,  and  unless  a  good  system 
is  exercised  in  keeping  a  count  of  the  number  so  used,  a  mistake  is  liable  to  be  made. 
Without  a  systematic  count  by  an  assistant  or  nurse,  the  operator  would  leave 
such  articles  in  the  peritoneal  cavity  more  frequently  than  is  now  the  case. 

In  clean  cases  when  a  good  technic  is  used  the  article  so  remaining,  especially  if 
small,  may  become  encysted  and  do  no  great  harm.  This,  however,  is  not  the  usual 
result,  for  by  the  irritation  caused  by  the  foreign  body  a  peritonitis  (generally  local) 
develops,  and  unless  the  patient  dies  as  a  result  of  it,  the  body  has  either  to  be  re- 
moved by  another  operation  or  to  work  its  way  out  through  the  abdominal  wall, 
vagina,  bowel,  or  bladder.  This  result  is  brought  about  by  the  suppuration  pro- 
duced by  the  body  and  the  breaking  down  of  tissue  near  it.  The  bacteria  of  suppu- 
ration may  be  introduced  during  the  operation,  may  be  brought  by  means  of  the 
circulation,  or  make  their  way  through  the  wall  of  the  intestine  after  this  has  been 
weakened  by  inflammation  and  pressure.  If  the  abscess  opens  into  the  intestine 
an  exhaustive  and  prolonged  diarrhea  may  result,  or  when  the  bladder  is  invaded 
cystitis,  at  times,  followed  by  suppuration  of  the  kidney  is  seen.  In  most  cases  the 
adhesions  which  form  around  the  body  involve  the  intestines  and  interfere  with 
their  peristaltic  movements  or  encroach  upon  their  lumen.  Hence  ileus,  complete 
or  partial,  is  frequently  seen.  Some  authors  have  given  drainage-tubes  and  other 
foreign  bodies  which  have  been  left  in  wounds  or  in  the  abdomen  as  a  cause  of  per- 
sistent mania. 

The  foreign  body  may  cause  symptoms  to  arise  almost  immediately  after  opera- 
tion, especially  where  it  is  not  sterile  or  where  its  presence  interferes  with  the  move- 
ments of  the  bowels.  In  other  instances  definite  symptoms  may  not  arise  for  weeks. 
In  most  cases,  however,  if  the  body  is  not  very  small  the  symptoms  finally  become 
so  marked  as  to  make  a  secondary  operation  necessary.  In  nearly  all  cases  there 
is  an  elevation  of  temperature,  an  increased  rapidity  of  pulse,  interference  with  the 
functions  of  the  bowels  or  bladder,  and  finally  the  body  causes  a  definite  abscess, 
which  may  point  in  the  abdominal  wall,  vagina,  bladder,  or  intestine. 

How  to  avoid  this  distressing  accident  is  a  most  important  question.  The 
following  rules  have  been  found  of  service : 

1.  Begin  the  operation  with  a  definite  number  of  sponges,  gauzes,  and  instru- 
ments, and  if  more  are  needed  have  the  nurse  get  out  the  same  number  or  simple 
multiples  of  them. 

2.  Make  the  assistant  or  nurse  who  hands  these  articles  responsible  for  their 
proper  count. 

3.  Do  not  change  assistants  or  nurses  until  the  articles  used  are  all  accounted 
for. 

4.  The  discarded  gauzes  and  sponges  should  be  placed  in  a  special  receptacle 
provided  for  them,  and  none  should  be  removed  from  the  operating  room  until 
the  abdomen  has  been  closed. 


58  COMPLICATIONS    FOLLOWIXG    OPERATIOXS. 

5.  No  gauzes  or  sponges  should  be  divided  during  operation. 

6.  Use  large  pieces  of  gauze  when  packing  off  the  intestines  and  have  a  piece 
of  tape  sewed  to  each.  Some  articles  should  be  attached  to  the  other  end  of  the 
tape;  clamps,  or  the  colored  and  perforated  marbles,  being  generally  used  for  this 
purpose. 

7.  At  the  end  of  the  operation  the  operator  should  demand  to  know  of  the  per- 
sons responsible  the  number  of  articles  missing,  and  should,  even  if  all  are  accounted 
for,  make  a  careful  search  of  the  field  of  operation  to  confirm  the  correctness  of 
the  reply. 

After  the  discovery  that  a  foreign  body  has  been  left  in  the  abdomen  is  made, 
no  time  should  be  lost  in  remo\ing  it.  In  most  cases  the  secondary  operation  is 
performed  for  the  conditions  caused  by  foreign  body  and  the  diagnosis  is  made  as  a 
consequence  of  the  operation.  The  wound  is  treated  upon  general  surgical  princi- 
ples, drainage  being  indicated  in  most  cases. 

Bodies  Left  in  Wounds. — Occasionally  non-absorbable  sutures,  drainage- 
tubes,  or  pieces  of  gauze  drains  are  not  removed  at  the  proper  time  and  are  a  source 
of  annoyance  and,  at  times,  of  actual  danger  to  the  patient.  Silkworm-gut  sutures 
which  are  used  inside  the  vagina  are  the  articles  most  often  left  behind,  their  removal 
being  in  many  cases  quite  difficult,  especially  in  nervous  women. 

Occasionally  after  hysterectomies  and  other  operations  where  a  vaginal  drain 
is  used  a  piece  of  gauze  is  left  behind  and  may  cause  much  troul)le.  Urinary  and 
fecal  fistulas  occasionally  result,  and  the  dense  intestinal  adhesions  wliich  form  in 
most  cases  may  interfere  seriously  with  the  movements  of  the  bowels. 

Only  a  conscientious  and  systematic  performance  of  duty  by  hospital  assistants 
and  a  careful  record  of  the  number  of  sutures  and  gauzes  used  and  removed  will 
prevent  the  occurrence  of  these  accidents.  A  good  rule  in  all  cases  is  to  make  a 
careful  examination  of  the  patient  at  the  time  of  her  discharge.  This  will  prevent 
the  occurrence  of  many  of  these  accidents  which  are  so  humiliating  to  the  operator 
and  anno}dng  to  the  patient.  AMien  a  suture  is  cut  off  and  left  behind,  it  is  wiser 
to  anesthetize  the  patient,  if  necessary,  and  remove  it  before  she  leaves  your  care. 

In  operations  upon  or  examination  of  the  bladder  cotton  pledgets  are  occasion- 
ally left  behind.  AMien  glass  catheters  are  used  they  are  liable  to  be  broken  and 
a  piece  left  in  the  bladder,  or  short  catheters  may  escape  from  the  hands  of  the 
person  using  them  and  slip  entirely  into  the  organ.  Likewise  sutures  which  have 
been  tied  inside  of  or  entered  the  mucous  membrane  of  the  bladder  have  to  be 
removed,  as  they  tend  to  become  nuclei  for  calculus-formation. 

The  foreign  body  may  be  passed  with  the  urine  and  give  no  trouble,  but  where 
this  does  not  occur  it  is  usually  the  source  of  much  discomfort  or  serious  danger 
to  the  woman.  The  symptoms  are  usually  those  of  cystitis,  with  or  without  pyuria 
or  hematuria. 

The  diagnosis  can  be  made  by  means  of  a  cystoscopic  examination.  This  is 
most  readily  done  by  means  of  the  Kelly  cystoscope,  by  the  use  of  which  the  nature 
of  the  trouble  can  be  ascertained  and  the  cause  ffenerallv  be  removed. 


POST-OPERATIVE    THROMBOSIS,    THROMBOPHLEBITIS,    AND    EMBOLISM.  59 

If  a  foreign  body  is  present  and  it  is  of  a  size  to  permit  its  passage  through  the 
cystoscope,  it  can  be  grasped  by  an  alligator  forceps  and  removed.  In  this  wav  one 
can  remove  pledgets,  rubber  bougies,  and  other  foreign  bodies.  Ligatures  mav  in 
like  manner  be  pulled  away  with  or  without  being  severed.  If  the  body  is  too 
large  to  permit  its  removal  in  this  way,  an  incision  should  be  made  through  the 
vesicovaginal  septum,  or  in  rare  cases  a  suprapubic  operation  is  indicated. 


POST-OPERATIVE  THROMBOSIS,  THROMBOPHLEBITIS,   AND  EMBOLISM. 

The  relation  existing  between  these  affections  is  so  close  that  they  will  be  con- 
sidered together,  and  a  brief  general  consideration  of  them  will  perhaps  not  be 
superfluous. 

A  thrombus  is:^  "A  solid  mass  or  plug  formed  in  the  li\ang  heart  or  blood-vessel 
from  the  constituents  of  the  blood.  ...  A  thrombus  formed  from  the  circu- 
lating blood  is  at  first  parietal  or  mural,  but  by  continued  growth  it  may  fill  the 
vessel,  and  thus  become  an  occluding  or  obstructing  thrombus.  A  primitive  or 
autochthonous  thrombus,  caused  by  local  conditions,  may  be  the  starting-point 
of  a  continued  or  propagated  thrombus,  extending  in  the  course  of  the  thrombosed 
vessel  and  perhaps  into  communicating  vessels.  A  secondary  or  encapsulating 
thrombus  is  one  which  starts  from  an  embolus  of  thrombotic  material.  A  continued 
thrombus  is  also  spoken  of  as  secondary.  .  .  .  The  thrombus  grows  in  length 
chiefly  in  the  direction  of  the  current  of  blood;  but  it  may  grow  in  the  opposite 
direction.  ...  A  venous  thrombus  extends  in  the  circulating  blood,  not  only 
as  far  as  the  next  branch,  but  frequently  a  greater  or  less  distance  beyond  it  in  the 
form  of  a  mural  thrombus." 

Thrombi  are  also  subdivided  into  cardiac,  arterial,  venous,  or  capillary,  accord- 
ingly as  they  occupy  one  of  these  portions  of  the  circulatory  system. 

The  general  causes  of  primary  thrombosis  are  given  as  follows:  A  slowing  or 
other  disturbance  of  the  blood-current,  changes  in  the  vessel  wall,  and  change  in 
the  blood  itself. 

The  following  classification,  having  as  a  basis  the  causation  of  thrombi,  has 
also  been  made : 

1.  Inflammatory  thrombi,  which  are  produced  through  acute  or  chronic  inflam- 
mation of  the  blood-vessel  wall.  As  a  consequence  of  the  inflammation,  the  vessel 
wall  is  thickened  and  the  endothelium  injured. 

2.  Traumatic  thrombi  produced  through  injuries  to  the  endothelium  by  trauma. 
To  this  classification  belong  those  thrombi  caused  by  ligation,  severing,  or  tearing 
of  the  vessel. 

3.  Compression  or  dilatation  thrombi  which  are  caused  by  a  slowing  of  the 
blood-stream.  The  compression  can  come  about  by  tumors,  exudates,  etc.;  and 
the  dilatation  may  be  due  to  actual  disease,  loss  of  elasticity,  or  excessive  thinning  of 
the  vessel. 

1  Welch,  W.  H.:  Allbutt's  "System  of  Medicine,"  1898,  vi,  155. 


60  COMPLICATIONS    FOLLOWING    OPERATIONS. 

4.  Marantic  thrombi  which  are  due  to  diseased  conditions  of  the  blood,  weakness 
of  the  heart,  and  slowing  of  the  blood-stream. 

The  causes  just  mentioned  may  act  conjointly  after  operation  to  produce  throm- 
bosis of  the  vessels.  It  is  a  well-established  fact  that  thrombi  are  very  liable  to 
occur  after  operations  for  myomas  or  carcinomas  of  the  uterus  and  large  ovarian 
tumors.  In  these  cases  the  blood-formation  is  interfered  with  by  loss  of  appetite 
and  general  ill  health  produced  by  the  pressure  of  the  tumor  causing  deficient  peris- 
talsis and  chronic  intestinal  obstruction;  the  nutrient  material  of  the  blood  is  utilized 
in  supplying  nutrition  to  the  rapidly  growing  tumor;  and  in  many  cases  large 
quantities  of  blood  are  lost  both  before  and  during  operation.  From  these  causes 
there  is  frequently  in  these  patients  marked  anemia  (the  hemoglobin  being  at  times 
reduced  to  20  per  cent,  or  to  30  per  cent,  of  the  normal),  the  number  of  white  blood- 
corpuscles  and  blood-platelets  and  the  amount  of  fibrin  are  relatively  increased, 
and  the  blood  is  thus  apparently  rendered  more  liable  to  coagulate.  Likewise  in 
many  of  these  cases  there  are  pathologic  changes  in  the  blood-vessels  and  at  times 
diseased  conditions  of  the  heart.  Pozzi,  Mahler,  Hofmeier,  and  others  have  re- 
ported cases  which  apparently  show  that  in  women  with  these  tumors  the  heart  is 
liable  to  hypertrophy  and  dilatation  and  the  heart  muscle  to  undergo  atrophic  or 
other  changes.  The  diseased  condition  of  the  blood  tends  to  cause  pathologic 
changes  in  the  endothelium  of  the  vessels,  and  in  consequence  of  pressure,  torsion, 
etc.,  the  veins  of  the  pelvis  and  lower  extremity  are  liable  to  become  dilated  and 
their  endothelium  diseased.  Finally,  where  infection  is  present  this  may  act  as  a 
cause  of  thrombosis  by  causing  inflammation  of  the  vessel  wall  as  well  as  by  pro- 
ducing changes  in  the  blood. 

Clamped  and  ligated  vessels  may  be  the  seat  of  the  primary  thrombus  which 
by  its  growth  so  involves  the  larger  trunks  as  to  produce  symptoms,  or  the  vessels 
of  the  pelvis  or  abdominal  walls  may  be  so  injured  by  the  pressure  of  the  retractors 
as  to  be  the  seat  of  thrombus  formation.  The  work  of  Carrel  and  Guthrie  seems 
to  show  that  injury  of  the  vessel  wall  by  infection,  trauma,  etc.,  has  more  influence 
on  thrombus  formation  than  changes  in  the  blood.  Experiments  by  Schwab  upon 
blood-coagulation  tend  to  confirm  this  assumption. 

Tuberculous  cachexia,  chlorosis,  gout,  and  almost  all  of  the  infectious  diseases 
are  given  as  causes  of  thrombosis,  and  some  of  them  are,  at  times,  etiologic  factors 
in  the  post-operative  variety  of  the  affection. 

Although  thrombosis  may  occur  in  any  portion  of  the  vascular  system  it  is  essen- 
tially an  affection  of  the  veins.  As  a  post-operative  affection  much  attention  has 
been  recently  attracted  to  the  so-called  phlebitis  or  thrombosis  of  the  femoral  vein. 
The  chief  interest  of  the  gynecologist  and  abdominal  surgeon  lies  in  the  occur- 
rence of  thrombosis  in  the  iliac  veins,  their  branches  (especially  the  femoral),  the 
ovarian  vein,  the  portal  vein,  and  the  mesenteric  arteries  and  veins. 

The  symptoms  produced  by  a  thrombosis  depend  upon  whether  the  vessel  is 
an  artery  or  a  vein,  whether  it  is  partially  or  entirely  occluded,  whether  the  thrombus 
is  bland  or  infected,  and  the  location  of  the  thrombus.     Under  favorable  circum- 


POST-OPERATIVE   THROMBOSIS,    THROMBOPHLEBITIS,    AND   EMBOLISM.  61 

stances  the  lumen  of  the  vessel  is  not  totally  occluded,  or  the  collateral  circulation 
is  quickly  established,  so  that  the  symptoms  are  not  marked. 

Arterial  thrombosis  except  as  secondary  to  embolism  is  extremely  rare  as  a 
post-operative  complication.  The  point  where  we  usually  see  it  is  an  artery  of  the 
lower  extremity.     The  symptoms  are  as  follows : 

At  first  there  is  pain,  which  is  usually  severe,  paroxysmal,  and  is  increased  by 
pressure  over  the  vessel.  The  artery  may  be  felt  as  a  hard,  sensitive  cord,  and 
below  the  thrombus  the  pulsation  of  the  artery  may  be  completely  obliterated. 
The  leg,  especially  about  the  ankle,  becomes  pale,  cold,  numb,  loses  in  a  varying 
degree  its  muscular  power,  and  may  be  very  sensitive  to  pressure.  The  skin  may 
become  mottled,  edema  is  usually  present,  and  unless  the  collateral  circulation  is 
quickly  established  or  the  vessel  is  not  completely  plugged,  gangrene  is  the  usual 
result. 

Thrombosis  of  the  veins  is  more  frequent  than  arterial  thrombosis  as  a  post- 
operative complication.  Schenck^  states  that  after  7130  gynecologic  operations 
in  the  Johns  Hopkins  Hospital  there  occurred  48  cases  of  thrombosis  of  the  veins 
of  the  lower  extremity.  The  operations  after  which  the  thrombosis  occurred  were 
as  follows : 

Perineal  alone 4 

Ovarian  cysts 9 

Hysteromyomectoniy  and  myomectomy 19 

Hysterectomy  for  carcinoma 5 

Suspension  of  the  uterus 3 

Suspension  of  the  uterus  with  repair  of  the  perineum • 4 

Hysterectomy  for  pelvic  inflammation 1 

Miscellaneous 3 

Albanus"  found  that  in  1140  laparotomies  in  the  new  General  Hospital  at  Ham- 
burg-Eppendorf  there  occurred  53  cases  of  recognized  venous  thrombosis.  All 
except  one  occurred  either  in  the  pelvic  veins  or  the  veins  of  the  lower  extremity. 
The  diseases  for  which  the  operations  were  performed  were  as  follows : 

Carcinoma  of  esophagus 1 

Diseases  of  stomach .' 8 

(Carcinoma,  6;   ulcer,  1;   pyloric  stenosis,  1.) 

Diseases  of  the  vermiform  appendix 10 

Diseases  of  the  large  bowel  (all  carcinomas) 3 

Diseases  of  the  liver  and  appendages 7 

(Liver  abscess,  1;  carcinoma  of  liver  and  gall-bladder,  1;  chronic  icterus,  1; 
diseases  of  the  gall-bladder,  4.) 

Subdiaphragmatic  abscess 2 

Ileus,   1 ;  perforative  peritonitis,   1 ;  general  carcinoma,   1 ;  sarcoma  of  the  ab- 
dominal wall,  1;    tuberculous  peritonitis,  1. 

Total 5 

Diseases  of  the  female  genital  tract 19 

(Carcinoma  of  ovary,  3;  carcinoma  of  uterus  and  ovaries,  1;  carcinoma  of 
uterus,  1 ;  pyosalpinx,  5;  ovarian  cysts,  4;  myoma  uteri,  3;  prolapsus  uteri, 
1;   extrauterine  pregnancy,  1.) 

^  Schenck,  B.  R.:  "A  Resume  of  Forty-eight  Cases  of  Post-operative  Crural  Thrombosis," 
N.  Y.  Med.  Jour.,  1902,  Ixxvi,  401-404. 

^  Albanus,  G.:  "Thrombosen  und  Embolien  nach  Laparotomien,"  Beitr.  z.  klin.  Chir.,  1903, 
xl,  311-330. 


62  COMPLICATIOXS   FOLLO"«aXG    OPERATIONS. 

Sonnenburg  in  1000  operations  for  appendicitis  observed  20  cases  of  thrombosis. 
These  were  distributed  as  follows: 

Right  leg 9 

Left  leg 6 

Both  legs 2 

Vena  porta 2 

Vena  cava 1 

Clark^  in  3000  celiotomies  performed  mainly  for  gynecologic  diseases  found  35 
cases  of  femoral  thrombosis.     The  diseases  were  as  follows: 

Myoma  uteri 16 

Cystoma  ovarii 10 

Retroflexio  uteri  (simple  and  adherent) 5 

Carcinoma  uteri 5 

Appendicitis 2 

Salpingitis  and  peri-oophoritis 2 

Floating  kidney 1 

Cancer  of  pylorus 1 

The  occurrence  of  thrombosis  in  the  veins  of  the  lower  extremity  is  thus  seen 
to  be  not  of  infrequent  occurrence.  One  generally  sees  the  affection  involving 
the  femoral  vein.  In  the  first  39  cases  of  femoral  thrombosis  which  were  observed 
in  the  gynecologic  wards  of  the  Johns  Hopkins  Hospital,  28  occurred  in  the  left 
leg,  8  in  the  right,  and  3  in  both  legs  at  the  same  time.  The  shortest  time  in  which 
symptoms  of  "phlebitis"  made  their  appearance  after  operation  was  seven  days, 
the  longest  twenty-eight,  and  the  average  time  sixteen  days.  The  affection  has 
followed  nearly  every  form  of  gynecologic  operation,  cases  having  been  seen  after 
curetage,  suspensio  uteri,  appendicectomy,  kidney  operations,  hysterectomy,  peri- 
neorrhaphy, etc.,  but  it  occurs  more  frequently  after  the  removal  of  large  pelvic 
tumors,  and  carcinomatous  uteri.  After  these  operations  most  of  the  conditions 
are  present  which  favor  thrombus  formation;  i.  e.,  there  is  anemia;  the  heart  is, 
at  times,  diseased,  and  there  is  slowing  of  the  blood-stream  due  to  lack  of  muscular 
exercise,  the  recumbent  posture,  etc.;  the  veins  of  the  lower  extremity  are,  in  conse- 
quence of  pressure  by  the  tumor,  dilated  and  their  walls  diseased;  the  pelvic  veins 
are  likewise  dilated  and  tortuous,  and  by  ligation,  bruising  by  clamps  and  retractors 
are  liable  to  be  the  seat  of  the  primarv^  thrombus.  Clark  lays  especial  stress  on  the 
probability  of  the  epigastric  veins  being  the  starting-point  of  the  thrombi  which 
finally  plug  the  femoral  vein. 

Infection  is  also  an  undoubted  factor  in  a  certain  number  of  cases. 

The  increased  frecjuency  with  which  thrombi  occur  in  the  left  femoral  vein  is 
thought  to  be  due  to  the  greater  length  and  obliquity  of  the  left  iliac  vein;  and  to 
its  passage  beneath  the  rectum  or  sigmoid  flexure  of  the  colon  and  the  right  iliac 
artery.  Pressure  by  these  structures  doubtless  causes  an  increased  tendency  to 
thrombus  formation.  This  pressure  is  increased  when  the  lower  bowel  is  distended 
by  fecal  matter  or  a  large  enema.  Of  greater  importance,  I  believe,  as  an  explana- 
tion of  this  increased  frequency  is  the  following:  Owing  to  its  greater  length  and 

'Clark,  J.  G.:  "Etiology  of  Post-operative  Thrombo-phlebitis,"  Univ.  Penna.  Med.  Bull., 
PhHa.,  1902,  v,  145,  146. 


POST-OPERATIVE    THROMBOSIS,    THROMBOPHLEBITIS,    AND    EMBOLISM.  63 

its  course  obliquely  across  the  posterior  wall  of  the  pelvis,  this  vessel  is  subjected  to 
greater  pressure  and  trauma  before  operation  in  cases  of  myomas  and  other  large 
pelvic  tumors.  As  we  have  seen,  femoral  thrombosis  occurs  much  more  frequently 
in  cases  of  these  tumors.  They  press  more  directly  on  the  left  iliac  vein  than  on 
the  right  one,  and  there  is  consequently  a  greater  tendency  to  dilatation  of  the  vessel 
walls  and  to  changes  in  the  endothelium  of  the  veins  of  the  left  leg.  As  a  conse- 
quence of  this  dilated  condition  of  the  vein  and  change  in  its  endothelium  there  is 
an  increased  tendency  to  thrombus  formation  after  operation. 

In  those  cases  where  thrombosis  takes  place  in  both  femoral  veins  the  process 
in  the  second  is  generally  an  extension  of  the  thrombus  from  the  side  first  involved 
by  way  of  the  common  iliac  veins. 

The  symptoms  of  thrombosis  of  the  pelvic  veins  where  the  external  iliac  is  not 
involved  are  obscure.  We  see  cases  of  pulmonary  embolism  following  thrombosis 
of  these  veins  when  the  convalescence  of  the  patient  had  apparently  been  normal. 
One  would  expect  some  elevation  of  temperature,  an  increased  pulse-rate,  and 
pelvic  pain.  These  symptoms  are  seen  so  frequently  after  celiotomies  that  their 
value  in  diagnosing  thrombosis  of  these  veins  is  small.  An  elevation  of  temperature 
to  100°  to  103°  F.  after  the  first  week,  a  relatively  rapid  pulse,  the  occurrence  of  a 
sudden  sharp  pain  in  the  chest,  or  a  localized  pleurisy  are  indicative  of  thrombosis 
of  the  pelvic  veins. 

In  thrombosis  of  the  femoral  vein  there  is  a  sudden  elevation  of  temperature  to 
100°  to  103°  F.,  seldom  preceded  by  a  chill  or  chilly  sensations.  It  has  been  stated 
that  there  is  a  relatively  greater  increase  in  the  pulse-rate  than  usually  accompanies 
this  amount  of  fever;  the  pulse  curve  is  irregular,  at  times  going  very  high,  and  the 
pulse  may  remain  rapid  after  the  fever  subsides.  This  relation  between  pulse 
and  temperature  was  not  a  striking  feature  in  my  cases  and  would  not  have  aided 
materially  in  making  a  diagnosis  even  after  the  condition  w^as  suspected.  Pain  is 
usually  the  first  symptom  to  attract  attention.  It  may  be  quite  severe  and  paroxys- 
mal, or  only  tenderness  along  the  vessel  and  pain  on  movement  of  the  affected  leg 
may  be  present.  The  pain  is  worse  in  the  groin,  inside  of  the  thigh,  popliteal  space, 
and  calf  of  the  leg.  Pricking  and  tingling  sensations  are  frequently  felt.  The 
edema,  which  varies  greatly  in  amount,  makes  its  appearance  early  in  the  course 
of  the  affection.  It  may  be  scarcely  noticeable,  moderate  in  amount,  or  the  limb 
may  be  firm  with  the  skin  smooth  and  tense.  The  leg  in  marked  cases  pits  on  pres- 
sure and  is  white  and  mottled  in  appearance.  The  vein  can,  at  times,  be  felt  as  a 
hard  cord,  especially  if  superficial,  where  it  may  be  seen  as  a  line  of  livid  red  color. 
The  surface  temperature  is  frequently  elevated  in  acute  cases.  Muscular  move- 
ments are  generally  restricted,  principally  on  account  of  the  pain.  The  symptoms 
may  be  more  pronounced  than  the  ones  described  above.  In  typical  phlegmasia 
alba  dolens  the  symptoms  are  more  marked,  the  leg  being  quite  elastic  and  pitting 
but  little  on  pressure.  Kronig  found  in  a  case  of  phlegmasia,  streptococci  in  the 
fat  and  connective  tissue  outside  the  blood-vessels,  and  in  typical  phlegmasia  there 
is  probably  lymphangitis  and  occlusion  of  the  lymph-channels  as  well  as  phlebitis. 


64  COMPLICATIONS    FOLLOWING    OPERATIONS. 

It  is  very  interesting  and  important  to  know  what  finally  becomes  of  the  thrombi. 
They  may  soften  or  break  down,  become  organized,  or  undergo  calcification.  The 
softenings  are  divided  into  simple  or  bland,  septic  or  purulent,  and  putrid.  The 
simple  softening  is  thought  to  be  due  to  the  action  of  a  ferment,  and  the  septic 
and  putrid  are  due  to  the  action  of  the  pyogenetic  and  putrefactive  bacteria  respec- 
tively. These  softenings  may  lead  to  the  dislodgment  of  pieces  of  the  thrombi, 
which  are  then  known  as  emboli,  and  these  are  transported  by  the  circulation  to 
various  parts  of  the  body.  When  calcification  occurs  phleboliths  or  arterioliths 
are  formed. 

The  organization  of  thrombi,  i.  e.,  the  substitution  for  the  thrombus  of  vascu- 
larized connective  tissue  takes  place  in  the  majority  of  cases.  The  tissue  which 
replaces  the  thrombus  is  derived  from  the  wall  of  the  blood-vessel,  new  blood-vessels 
springing  from  the  vasa  vasorum,  and  the  endothelium  and  connective  tissue  being 
derived  from  like  cells  in  the  vessel  wall.  Lacunar  spaces  lined  with  endothelium 
may  form  throughout  the  thrombus,  the  latter  becoming  gradually  disintegrated 
and  absorbed.  The  newly  formed  tissue  becomes  fibrous  and  contracts  and  there 
may  result  a  fibrous  plug,  a  cavernous  structure  with  blood-spaces,  or  a  restoration 
of  the  lumen  of  the  vessel  with  perhaps  a  few  bands  crossing  it. 

The  prognosis  of  a  thrombosis  of  the  veins  of  the  lower  extremity  is  usually 
very  good,  the  chief  danger  being  pulmonary  embolism.  Pulmonary  embolism 
occurred  twice  in  the  48  cases  of  thrombosis  reported  by  Schenck,  but  neither 
proved  fatal.  Albanus  in  his  1140  cases  of  laparotomy  saw  23  cases  of  embolism, 
all  but  one  occurring  in  the  lungs.  Riedel  reports  4  cases  of  thrombosis,  one  of 
which  died  of  pulmonary  embolism.  In  Sonnenburg's  series  of  1000  cases  of  appen- 
dicitis, with  20  cases  of  thrombosis  there  were  3  deaths  from  pulmonary  embo- 
lism and  2  from  what  he  considered  to  be  embolic  pneumonia.  In  86  autopsies 
upon  cases  where  death  was  due  to  appendicitis,  Kelly  and  Hurdon  found  3 
cases  of  pulmonary  embolism.  The  sequelce  are,  as  a  rule,  not  marked.  There  is 
usually  a  slight  edema,  especially  upon  using  the  limb,  for  several  weeks,  accom- 
panied by  stiffness  and  pain,  and  in  exceptional  cases  we  see  chronic  edema,  stiffness 
and  pain,  which  persist  for  months  or  years.  Elephantiasis,  varicose  veins,  chronic 
ulcer,  neuritis,  muscular  atrophy  or  hypertrophy,  and  club-foot  are  also  given  as 
sequelae.     Gangrene  perhaps  never  occurs  in  uncomplicated  cases. 

The  prophylaxis  of  post-operative  thrombosis  consists  in  scrupulous  asepsis,  in 
care  during  operation  to  prevent  undue  bruising  and  trauma  of  the  blood-vessels 
of  the  abdominal  wall  and  pelvis,  and  in  improving  the  general  condition  of  the 
patient  before  operation,  when  possible,  by  rest  in  bed,  good  food,  careful  attention 
to  the  condition  of  the  bowels,  and  the  administration  of  iron,  arsenic,  etc.,  to  in- 
crease the  amount  of  the  hemoglobin. 

The  indications  for  treatment  are  two:  to  prevent  the  occurrence  of  pulmonary 
embolism,  and  to  promote  the  absorption  and  organization  of  the  thrombus.  These 
indications  are  met  by  rest,  position,  and  general  hygienic  rules.  In  femoral 
thrombosis  the  patient  should  remain  in  the  recumbent  position  for  six  weeks  with 


POST-OPERATIVE   THROMBOSIS,    THROMBOPHLEBITIS,    AND    EMBOLISM.  65 

as  little  movement  of  the  affected  limb  as  is  possible,  the  limb  should  be  well  wrapped 
in  some  soft  substance,  kept  slightly  elevated,  and  have  applications  of  soothing 
lotions,  as  lead-water  and  laudanum,  once  or  twice  a  day.  Rubbing  and  tight 
bandaging  are  absolutely  contraindicated.  The  usual  rules  relating  to  the  general 
condition  of  the  patient  are  applicable  to  these  cases.  After  six  weeks,  if  the  local 
symptoms  have  all  disappeared,  the  danger  of  embolism  may  be  considered  as  past, 
and  gentle  massage  and  bandaging  may  be  employed  or  an  elastic  stocking  may  be 
worn.     When  gangrene  occurs  amputation  of  the  limb  is  necessary. 

Embolism. — Embolism  is  defined  as  the  impaction  in  some  part  of  the  vas- 
cular system  of  any  undissolved  material  brought  there  by  the  blood-current. 
The  transported  material  is  called  an  embolus.  The  emboli  are  usually  dislodged 
pieces  of  thrombi,  but  may  consist  of  fat,  air,  tumor-cells,  etc.  A  thrombus  from 
the  systemic  veins  or  the  right  heart  causes  a  pulmonary  embolism  except  in  those 
rare  cases  of  crossed  embolism  where  the  embolus  passes  through  an  open  foramen 
ovale.  When  a  piece  of  a  thrombus  is  detached  from  the  left  side  of  the  heart, 
the  pulmonary  veins,  or  the  systemic  arteries,  the  embolus  lodges  in  a  systemic 
artery. 

Fat  emboli  are  of  little  importance  in  gynecology,  although  some  authors  think 
that  under  certain  conditions  they  cause  lung  complications.  Air,  which  occa- 
sionally enters  the  veins  during  operation,  causes  signs  of  cardiac  embarrassment 
and  at  times  death.  This  form  of  embolism  is  extremely  rare  after  abdominal 
operations. 

Pillmonary  embolism  is  the  one  of  chief  importance.  This  is  of  compara- 
tively frequent  occurrence,  much  more  so,  perhaps,  than  is  generally  believed. 
The  principal  sources  of  pulmonary  embolism  following  gynecologic  and  abdom- 
inal operations  are  the  ovarian  and  the  branches  of  the  common  iliac  veins.  There 
seems  to  be  a  special  liability  for  pulmonary  embolism  to  occur  after  operations  for 
ovarian  tumors,  myomas,  carcinomas,  and  incarcerated  hernise.  The  embolism 
generally  takes  place  between  the  first  and  fourth  week  after  the  formation  of  the 
thrombus,  although  one  sees  it  not  infrequently  within  a  few  days  after  operation, 
and  occasionally  also  later  than  the  fourth  week. 

In  a  considerable  portion  of  the  cases  of  pulmonary  embolism  the  thrombi 
exist  at  the  time  of  operation,  and  the  embolus  is  set  free  either  by  the  manipulation 
of  operation  or  by  the  removal  of  pressure  in  the  veins.  In  a  case  seen  in  Zweifel's 
clinic  the  fatal  pulmonary  embolus  coming  from  the  femoral  vein  followed  the 
drainage  of  an  abscess  in  the  right  iliac  region.     • 

The  symptoms  of  a  pulmonary  embolus  depend  upon  the  size  of  the  vessel 
which  is  obstructed,  the  rapidity  and  completeness  of  the  obstruction,  the  nature 
of  the  embolus,  and  the  general  condition  of  the  heart,  lungs,  etc.,  of  the  patient. 
When  the  embolus  is  large  and  the  pulmonary  artery,  its  chief  branches,  or,  it  may 
be,  one  of  them  is  plugged,  death  may  be  instantaneous  or  ensue  in  a  few  minutes. 
Usually  the  patient  gives  a  sharp  cry,  sits  up  suddenly  in  bed,  complains  of  great 
precordial  distress,  and  gasps  for  breath.     The  auxiliary  muscles  of  respiration 

VOL.  II — 5 


66  COMPLICATIONS   FOLLOWING    OPERATIONS. 

stand  out  prominently,  the  cervical  veins  are  distended,  and  the  patient  shows 
marked  signs  of  collapse.  The  heart's  condition  may  be  tumultuous,  or  slower  than 
usual.  It  is  generally  weak  and  irregular.  The  pulse  varies  greatly,  in  some 
cases  slow,  full,  and  irregular,  and  in  others  almost  imperceptible  at  the  wrist. 
There  is  pallor  followed  by  cyanosis.  One  sees  at  times  convulsions  and  opistho- 
tonos. The  patient  usually  dies  from  syncope.  The  physical  signs  do  not  indicate 
the  lesion,  the  full  stridulous  breathing  being  the  only  thing  brought  out  usually  by 
an  examination  of  the  chest.  When  the  embolus  does  not  totally  occlude  the  vessel 
or  vessels,  the  patient  may  live  several  hours  and  die  as  a  result  of  the  secondary 
thrombosis,  and  here  the  same  symptoms  are  seen,  but  they  are  not  so  pronounced 
as  in  the  rapidly  fatal  cases.  When  a  small  vessel  is  plugged  there  results  usually 
a  hemorrhagic  infarction  of  a  limited  extent.  The  occurrence  of  the  infarction  is 
indicated  by  chilly  sensations,  dyspnea,  pain  in  the  chest,  and  localized  pleurisy. 
Blood-stained  sputum  is  frequently  seen  and  profuse  hemoptysis  is  occasionally 
present.  Examination  of  the  lungs  may  show  changes,  but  the  diagnosis  cannot 
be  made  in  most  cases  by  means  of  it,  as  it  is  generally  impossible  to  differentiate 
these  cases  from  some  other  affections  of  the  lungs  which  follow  serious  operations 
in  which  anesthesia  has  been  employed,  such  as  bronchopneumonia.  Even  after 
grave  symptoms  have  arisen  in  pulmonary  embolism  the  patient  may  recover. 
If  the  embolus  is  infected,  the  effects  and  symptoms  are  those  of  bland  emboli,  to 
which  are  superadded  the  specific  effects  of  the  bacteria  with  which  they  are  infected, 
and  abscesses,  gangrene,  etc.,  may  supervene. 

The  diagnosis  is  based  upon  the  sudden  and  characteristic  s}Tnptoms  and  the 
existence  of  a  recognized  source  of  an  embolus.  In  any  case  where  a  pleurisy  of  a 
limited  extent  or  evidence  of  small  areas  of  pulmonary  inflammatory  changes  is  seen 
after  operation,  the  probability  of  an  embolic  cause  should  always  be  considered. 

The  treatment  is  for  the  most  part  prophylactic.  After  the  embolism  has  occurred 
little  can  be  done.  Hypodermic  injections  of  camphor  or  brandy  should  be  used 
to  control  the  collapse,  and  if  the  cyanosis  is  marked,  oxygen  should  be  adminis- 
tered. Unfortunately,  in  most  cases  one  suspects  nothing  until  the  patient  suddenly 
dies  of  an  embolus  from  one  of  the  thrombosed  pelvic  veins.  Following  operations 
nurses  should  be  trained  not  to  rub  the  lower  extremities  of  the  patients  who  com- 
plain of  pain  there,  without  instructions.  In  cases  of  post-operative  pleurisy,  or 
sudden  sharp  pain  in  the  chest  with  rapid  and  irregular  pulse,  the  surgeon  should 
think  of  embohsm  and  precautions  should  be  taken  to  keep  the  patient  quiet. 

Embolism  and  thrombosis  in  the  veins  or  arteries  of  the  intestines  are 
of  great  interest  to  the  surgeon,  and  occasionally  occur,  after  laparotomies,  as  a 
result  of  incarcerated  hernia,  after  appendicectomy,  and  in  certain  cases  of  intes- 
tinal obstruction.  Delatour  reports  a  case  following  splenectomy.  The  symptoms 
of  thrombosis  and  embolism  in  this  region  are  essentially  the  same.  In  the  majority 
of  instances  they  occur  in  the  superior  mesenteric  artery  or  its  branches.  An 
embolism  of  an  artery  or  a  thrombosis  of  a  vein  or  artery  of  considerable  size  is 
generally  followed  by  a  hemorrhagic  infarction  of  the  intestines.     The  infarction 


POST-OPERATIVE   THROMBOSIS,    THROMBOPHLEBITIS,    AND    EMBOLISM,  67 

may  be  complete  or  partial,  and  its  extent  depends  upon  the  size  of  the  vessel  plugged. 
The  symptoms  may  be  slight  if  the  thrombosed  vessel  is  small,  and  it  is  probable 
that  many  of  the  post-operative  ulcers  of  the  stomach  and  intestines  are  due  to  the 
occurrence  of  an  embolus  or  thrombus  in  a  vessel  supplying  the  part.  In  the 
recognized  cases  the  symptoms  are  well  marked  and  extremely  severe.  At  first 
there  is  intense  colicky  pain  and  abdominal  tenderness,  and  this  is  quickly  followed 
by  all  the  signs  of  intestinal  obstruction,  to  which  are  generally  added  the  presence 
of  dark  tarry  blood  in  the  stools  and  the  vomiting  of  bloody  material.  The  symp- 
toms are  practically  those  of  acute  obstruction  of  the  intestines  and  the  case  is  usually 
so  diagnosed  and  treated.  One  finds  on  opening  the  abdomen  that  the  affected 
intestines  are  distended,  thickened,  edematous,  and  of  a  dark  red  color.  The 
peritoneal  covering  is  lusterless  and  covered  with  a  fibrinous  or  fibrino-purulent 
exudate.  There  may  be  a  general  peritonitis,  as  the  bacteria  from  the  intestine 
quickly  invade  the  general  cavity.  Bloody  fluid  may  be  found  in  the  peritoneal 
cavity.  The  mucous  membrane  of  the  affected  intestine  is  in  places  necrotic  and, 
at  times,  covered  with  a  diphtheritic  membrane.  The  mesentery  is  edematous, 
thickened,  and  contains  extravasated  blood.  The  prognosis  is  very  grave,  but  a 
few  cases  of  infarction  of  the  intestine  have  recovered  following  resection  of  the 
infarcted  portion. 

The  treatment  is  either  symptomatic  in  cases  of  ulcers,  or  in  severe  cases  that 
given  for  ileus  with  gangrene. 

An  embolism  or  a  rupture  of  one  of  the  blood-vessels  of  the  brain  may 
occur  during  anesthesia  or  as  a  post-operative  complication.  The  symptoms  of 
the  two  affections  being  almost  identical,  they  will  be  considered  together.  The 
stage  of  excitement  of  the  anesthesia  would  seem  to  be  the  time  when  a  rupture  of  a 
vessel  would  be  most  likely  to  take  place.  When  an  embolism  occurs  the  plug 
usually  lodges  in  the  middle^  cerebral  artery.  In  some  of  these  cases  the  patient 
does  not  regain  consciousness  after  the  operation;  in  others  the  symptoms  which 
indicate  the  lesion  are  found  when  she  comes  from  under  the  effects  of  the  anesthetic ; 
and  in  others  still,  especially  in  embolism,  the  symptoms  may  develop  at  almost 
any  time  during  the  convalescence.  Hemiplegia,  hemianesthesia,  crossed  paraly- 
sis, and  other  well-known  symptoms  may  be  present.  In  embolism  the  premonitory 
signs  are  absent,  the  prognosis  is  more  favorable,  and  the  duration  of  the  paralysis, 
etc.,  is  shorter,  as  a  rule,  than  in  apoplexy.  If  the  embolus  is  infected  an  abscess 
may  result,  but  in  some  cases  of  embolism  the  patient  soon  regains  the  use  of 
the  paralyzed  muscles.  These  complications'  are  rare  after  gynecologic  operations, 
but  I  have  recently  seen  two  cases  of  post-operative  cerebral  embolism  in  the  service 
of  I.  S.  Stone  at  the  Columbia  Hospital  in  Washington,  D.  C,  one  following  the  re- 
moval of  a  myomatous  uterus  and  the  other  after  a  gall-bladder  operation.  Byron 
Robinson  reports  several  cases  in  which  he  thought  death  was  caused  by  an  embol- 
ism in  the  floor  of  the  fourth  ventricle,  as  both  cardiac  and  respiratory  centers 
seemed  paralyzed  at  once. 

Thrombosis  or  embolism  of  the  coronary  arteries  of  the  heart  may  excep- 


68  COMPLICATIONS   FOLLOWING   OPERATIONS. 

tionally  occur  after  operation,  and  should  always  be  considered  in  looking  for  the 
cause  of  sudden  death. 

Thrombosis  and  embolism  may  occur  in  the  vessels  of  the  spleen  and  kidney 
after  operation.  Infarcts  of  these  organs  frequently  result  from  such  conditions  and 
abscesses  of  embolic  origin  are  sometimes  seen  in  them  in  cases  of  pyemia.  The  diag- 
nosis of  an  infarct  cannot  be  made  with  any  degree  of  certainty  when  suppuration 
is  not  present.  In  infarction  of  the  kidney,  pain  and  hematuria  are  generally  present, 
while  in  splenic  infarction  pain  and  a  splenic  friction  rub  are  the  chief  diagnostic 
symptoms.  When  abscesses  ensue  there  is  fever,  enlargement  of  the  organ,  and 
in  case  of  kidney  abscess  pyuria  is  generally  seen. 

Thrombosis  of  the  portal  vein  may  occur  after  operation  and  is  usually  of 
the  septic  variety.  The  infectious  process  may  invade  the  vein  from  foci  in  its 
vicinity,  such  as  follow  operations  upon  gall-bladder  or  bile-ducts,  or  extend  to 
the  vein  from  one  of  its  tributaries.  A  number  of  cases  of  infected  pylephlebitis 
and  liver  abscess  have  been  reported  following  operations  upon  the  vermiform 
appendix.  Gerster^  in  1189  cases  of  appendicitis  saw  9  cases  of  septic  pylephlebitis. 
He  says:  "The  primary  thrombus  is  seen  extending  gradually  and  continuously 
or,  in  short  intervals  of  space,  upward  toward  the  center,  rarely  involving  the  entire 
circumference  of  the  lower  course  of  the  portal  vein,  but  more  commonly  forming 
laterally  adherent  thrombi,  alongside  of  which  the  blood-current  may  pass  with 
little  interruption.  Completely  obturating  thrombi  are  generally  found  near  and 
about  the  entrance  into  the  liver,  either  in  the  trunk  of  the  portal  vein,  which  is 
rare,  or  more  commonly  in  one  or  the  other  or  in  both  of  its  branches.  The  process 
of  infection  is  a  slowly  progressive  one  by  continuity,  and  results  in  the  formation  of 
a  more  or  less  extensive  septic  thrombus  of  unequal  mass  and  thickness  and  of 
varying  consistency." 

Quincke  considers  appendicitis  second  only  to  dysentery  as  a  cause  of  liver 
abscess,  and  then,  in  frequency,  follows  cholelithiasis.  Langfeld  in  112  cases  of 
appendicitis  saw  pylephlebitis  four  times.  Fitz  in  257  cases  of  appendicitis  saw 
pylephlebitis  and  infection  of  the  hver  in  11  cases.  Hart,  Sonnenburg,  Baren- 
sprung,  Kelly,  and  numerous  other  writers  report  cases  of  the  same  kind. 

The  thrombotic  process  may  extend  to  the  portal  vein  through  the  mesenteric 
veins  from  the  intestine,  or  by  anastomosis  from  a  pelvic  vein  due  to  an  infection 
of  the  uterus  or  its  appendages. 

Thrombosis  of  the  bland  variety  is  probably  of  much  less  frequent  occurrence 
in  the  portal  vein. 

"The  diagnosis  of  obstruction  of  the  portal  vein  can  rarely  be  made.  A  sug- 
gestive symptom,  however,  is  a  sudden  onset  of  the  most  intense  engorgement  of 
the  branches  of  the  portal  system,  leading  to  hematemesis,  malena,  ascites,  and 
swelling  of  the  spleen."       (Osier.)     Emboli  occur  much  more  frequently  in  the 

'  Gerster,  A.  G.:  "On  Septic  Thrombosis  of  the  Roots  of  the  Portal  Vein  in  Appendicitis  and 
on  Pylephlebitis,  together  with  Some  Remarks  on  Peritoneal  Sepsis,"  Med.  Rec.,N.  Y.,  1903,  Ixiii, 
1005-1015. 


POISONING    BY   DRUGS.  69 

branches  of  the  portal  vein,  but  do  not,  as  a  rule,  lead  to  infarction  of  the  liver. 
"Although  the  intrahepatic  artery  and  portal  vein  are  terminal  vessels,  their  capil- 
lary communications  are  so  abundant  that,  as  a  rule,  emboHsm  or  thrombosis  of 
the  hepatic  vessels  causes  no  interference  with  the  circulation  of  the  liver."  (Welch.) 
When  the  embolus  occurs  in  an  artery  of  the  extremities,  the  symptoms  are 
almost  identical  with  those  described  under  arterial  thrombosis.  In  embohsm 
the  advent  of  the  pain  is  more  sudden  and  severe,  and  this,  with  the  existence  of  a 
lesion  of  the  left  heart,  would  serve  to  distinguish  it  from  thrombosis, 

POISONING  BY  DRUGS. 

It  is  impossible  in  this  chapter  to  go  into  the  symptoms  and  treatment  of  poison- 
ing by  every  drug,  but  a  few  words  to  indicate  how  to  recognize  the  cases  which 
are  liable  to  follow  operations  and  to  point  out  the  more  common  s\Tnptoms  of 
the  important  ones  will  perhaps  not  be  out  of  place. 

In  purpuric  rashes  one  should  always  consider  quinin,  mercury,  copaiba, 
belladonna,  ergot,  and  the  iodids  as  possible  causes.  Very  small  quantities  of 
these  drugs  may  call  forth  extensive  ecchymoses.  Osier  reports  a  case  of  marked 
purpura  in  a  man  after  the  administration  of  the  iodid  of  potash  for  ten  davs.  I 
have  recently  seen  a  young  woman  who,  after  taking  two  grains  of  quinin  in  com- 
bination with  iron  and  strychnin,  developed  extensive  purpura.  She  had  an  idio- 
syncrasy for  the  drug,  having  had  a  similar  eruption  on  two  other  occasions  from 
taking  it. 

Erythema  may  arise  after  the  administration  of  many  drugs,  chief  among  which 
are  quinin,  belladonna,  cannabis  indica,  hyoscyamus,  stramonium,  chloral  hydrate, 
antipyrin,  opium,  and  carbolic  acid. 

Eruptions  having  the  form  of  papules,  vesicles,  or  pustules  may  follow  the 
administration  of  the  bromids,  iodids,  mercury,  arsenic,  and  a  few  other  drugs. 

Urticaria,  at  times,  follows  the  administration  of  opium,  belladonna,  cannabis 
indica,  turpentine,  etc. 

Insanity  is  reported  to  have  occurred  after  the  use  of  iodoform,  belladonna, 
eserin,  salicylic  acid,  and  the  salicylates. 

The  post-operative  administration  of  strychnin  as  a  routine  is  followed  in 
many  clinics,  and  symptoms  of  poisoning  are  occasionally  seen.  The  first  indica- 
tions of  strychnin  poisoning  are  stiffness  of  the  muscles  of  the  neck  and  face,  in- 
creased reflex  muscular  excitability  so  that  a, sudden  noise  or  touch  causes  a  violent 
movement,  muscular  twitching,  and  restlessness.  Finally  opisthotonos  and  the 
classic  symptoms  arise. 

In  poisoning  by  atropin  and  other  members  of  this  group  the  characteristic 
symptoms  are  dilated  pupils,  drsTiess  of  the  mouth  and  throat,  quickened  pulse 
and  respiration,  rash,  restlessness  and  garrulity,  and  finally  depression,  ending  in 
stupor  and  coma. 

In  opium  poisoning  the  diagnosis  is  based  upon  the  following  s^nnptoms: 
Drowsiness  followed  by  deep  sleep,  contracted  pupils,  slowed  respiration,  the  num- 


70  COMPLICATIONS    FOLLOWING    OPERATIONS. 

ber  of  which  may  finally  be  only  three  or  four  to  the  minute,  with  cyanosis  and 
dryness  of  the  mouth  and  throat. 

Poisoning  from  mercury  is  perhaps  more  liable  to  occur  as  a  post-operative 
complication  than  from  any  other  drug,  many  persons  being  very  susceptible  to 
its  action.  The  administration  of  a  few  grains  of  calomel  as  a  purgative,  the  irri- 
gation of  a  raw  surface,  or  the  giving  of  a  vaginal  douche  when  a  bichlorid  solution 
is  used  may  cause  symptoms  of  mercuriahzation  to  arise.  The  symptoms  first 
intimating  this  trouble  are  a  foul  breath,  sore  gums  and  teeth,  increased  flow  of 
saliva,  diarrhea,  and  a  rash. 

Iodoform  impregnated  in  gauze  or  used  as  a  dusting-powder  is  largely  used 
as  a  surgical  dressing,  and  occasionally  poisoning  from  its  use  is  supposed  to  occur. 
Cushny^  gives  the  symptoms  as  follows:  "The  symptoms  of  iodoform  intoxication 
in  man  generally  set  in  with  anxiety,  general  depression,  and  discomfort.  The 
patient  becomes  sleepless  and  restless,  complains  of  giddiness  and  headache,  and 
often  of  the  taste  and  odor  of  iodoform  in  the  mouth  and  nose.  The  pulse  is  gen- 
erally greatly  accelerated,  and  a  rise  of  temperature  is  said  to  have  occurred  in 
some  cases  in  which  no  septic  poisoning  could  be  found  to  account  for  it.  The 
depression  deepens  into  true  melancholia  accompanied  by  hallucination,  the  patient 
often  suffering  from  the  illusions  of  persecution  which  may  induce  him  to  attempt  sui- 
cide. As  a  general  rule  this  melancholia  is  followed  by  attacks  of  violent  deHrium 
and  mania  lasting  for  hours  and  days,  and  n  fatal  cases  by  collapse  and  death. 
In  other  cases  the  condition  has  passed  into  permanent  insanity  and  dementia.  A 
rarer  result  of  the  absorption  of  iodoform  is  deep  sleep  passing  into  stupor  and 
collapse  without  any  sign  of  cerebral  excitement." 

In  milder  cases  of  poisoning  the  patient  suffers  only  from  the  unpleasant  taste 
and  odor,  from  headache,  and  not  infrequently  from  nausea  and  vomiting. 

A  rash  and  at  times  a  dermatitis  is  seen  after  the  use  of  this  drug.  The  urine 
usually  contains  iodin,  as  can  be  shown  by  tests. 

Most  cases  of  iodoform  poisoning  in  gynecology  are  due  to  packing  large  cavi- 
ties with  the  gauze.  In  instances  where  an  extensive  use  of  the  gauze  is  needed 
the  excess  of  iodoform  should  be  washed  out  of  it  before  using  it  as  a  pack. 

Carbolic  acid  poisoning  as  a  post-operative  complication  is  rare,  but  it  may 
occur.  It  can  arise  from  being  taken  internally  or  be  absorbed  from  the  skin,  a 
wound,  or  a  mucous  membrane.  When  large  quantities  are  absorbed,  almost  im- 
mediate unconsciousness  may  result  and  death  take  place  in  a  few  minutes.  It  is 
usually  absorbed  in  small  quantities,  when  there  occurs  headache,  depression,  nausea 
and  vomiting,  pallor,  and  collapse  with  irregular  pulse  and  respiration.  Fainting 
and  unconsciousness  may  finally  come  on.  Delirium  and  excitement  are  observed 
at  times.     The  urine  becomes  a  smoky,  dark  green  color. 

It  is  a  good  plan  before  the  use  of  mercury,  quinin,  iodoform,  or  any  drug  which 
may  produce  unpleasant  symptoms  to  inquire  if  the  patient  has  a  known  idiosyn- 
crasy for  it. 

1  Cushny,  A.  R.:  "Text-book  of  Pharmacology  and  Therapeutics,"  1903,  521. 


MALARIA.      TYPHOID    FEVER.  71 


MALARIA. 


Malarial  paroxysms  developing  during  convalescence  are  always  startling,  and 
in  cases  where  the  parasite  cannot  be  found,  the  cause  of  the  trouble  may  remain 
in  doubt  for  days. 

The  diagnosis  depends  principally  upon  the  history  of  the  case,  the  nature  of 
the  temperature  curve,  the  absence  of  any  known  cause  for  the  chills  and  fever, 
and  the  blood  examination.  The  points  in  the  latter  to  be  specially  considered 
are:  (1)  the  presence  or  absence  of  the  malarial  organism,  (2)  the  positive  or  nega- 
tive result  of  Widal's  test,  (3)  whether  or  not  there  is  a  greater  leukocytosis  than 
one  would  expect  during  convalescence  from  the  operation  through  which  the 
patient  had  been.  The  presence  of  the  organism  would  make  the  diagnosis  positive, 
although  this  would  not  exclude  some  possible  coexisting  disease  whose  symptoms 
resemble  those  of  malaria.  A  positive  result  from  Widal's  test  would  point  to 
typhoid  fever,  while  the  absence  of  an  increase  in  the  leukocytes  in  the  presence 
of  fever  would  indicate  typhoid  or  malaria.  In  suspected  cases  the  blood  should  be 
carefully ,.and  if  necessary  repeatedly,  examined  for  the  parasite  before  giving  quinin. 
In  malarial  districts  there  is  a  tendency  to  attribute  to  malaria  most  unexplained 
elevations  of  temperature.  There  should  be  a  careful  examination  of  the  seat  of 
operation,  chest,  urine,  bowels,  etc.,  before  quinin  is  administered  in  cases  where 
the  parasite  is  not  found. 

The  treatment  of  malaria  is  not  materially  modified  by  the  development  of 
the  disease  after  operation. 

TYPHOID  FEVER. 

Occasionally  typhoid  fever  arises  after  gynecologic  operations,  and  is  then  a 
serious  complication.  In  some  cases  the  patient  is  suffering  with  typhoid  at  the 
time  of  operation  and  the  proper  diagnosis  is  not  made,  or  the  two  diseases  happen 
to  be  coincident,  the  gynecologic  usually  being  chronic.  Among  our  9000  cases 
there  is  a  record  of  7  cases  of  typhoid  fever.  Of  these,  3  were  admitted  with  a 
diagnosis  of  some  gynecologic  disease  and  the  error  discovered  after  admission; 
3  were  operated  upon  for  some  gynecologic  disease  when  the  principal  symptoms 
were  due  to  typhoid;  and  in  one  case  the  fever  developed  several  weeks  after  opera- 
tion. The  principal  points  in  the  diagnosis  may  be  better  unpressed  by  giving 
briefly  a  few  cases. 

1.  A  girl  fifteen  years  old  was  sent  several  hundred  miles  to  the  hospital  with 
a  diagnosis  of  some  disease  of  the  urinary  tract.  She  gave  a  history  of  having 
had  an  attack  of  typhoid  fever  four  years  before  admission.  She  had  been  com- 
plaining several  months  prior  to  the  entrance  to  the  hospital  and  "broke  down" 
three  weeks  before  admission.  Upon  admission  she  complained  of  headache, 
backache,  anorexia,  and  burning  micturition.     Her  temperature  was  103°  to  104°  F. 

The  examination  of  chest  and  abdomen  was  negative  and  the  rectal  examination 
did  not  show  anything  abnormal. 


72  COMPLICATIONS   FOLLOWING    OPERATIONS. 

The  urine  contained  a  trace  of  albumin,  a  few  casts  and  pus  cells,  and  gave 
the  diazo  reaction.  Examination  of  urine  for  the  bacillus  of  tuberculosis  was 
negative.  Hemoglobin  65  per  cent.  Leukocytes  8500.  Widal's  reaction  was 
positive. 

Diagnosis,  typhoid  fever.  The  patient  was  transferred  to  the  medical  depart- 
ment, where  the  disease  ran  its  usual  course  and  the  patient  was  discharged  well. 

The  diagnosis  was  based  upon  a  negative  physical  and  pelvic  examination,  a 
low  leukocyte  count,  and  a  positive  Widal  reaction. 

2.  Another  case,  which  was  more  deceptive,  was  the  following:  A  chorus  girl 
entered  the  hospital  giving  a  history  o~f  having  had  a  criminal  abortion  performed 
in  another  city  three  months  before  admission.  This  was  followed  by  a  pelvic 
abscess  which  had  been  drained  through  the  vagina  and  a  drainage-tube  inserted. 
She  entered  the  hospital  with  the  drainage-tube  still  in  situ.  (It  had  been  inserted 
three  weeks  before.) 

She  complained  of  fever,  abdominal  pain,  malaise,  and  headache.  Her  tem- 
perature was  103°  F.  and  her  pulse  110. 

The  examination  of  the  chest  and  abdomen  was  negative,  and  the  vaginal 
examination  revealed  the  drainage-tube  and  the  opening  into  the  cul-de-sac  of 
Douglas,  but  was  otherwise  negative.  Her  urine  gave  the  diazo  reaction  but  was 
otherwise  normal.  The  drainage-tube  was  removed  and  she  was  given  antiseptic 
vaginal  douches.  The  temperature  rose  to  104°  F.  in  twenty-four  hours.  Her 
leukocytes  numbered  5500  at  the  first  count  and  3300  at  the  second.  Widal's  test 
proved  positive  and  rose  spots  could  now  be  seen.  The  diagnosis  of  typhoid  fever 
was  made  and  she  was  transferred  to  the  general  medical  department. 

3.  The  following  case  was  even  more  misleading,  and  in  this  there  existed  both 
the  uterine  disease  and  typhoid  fever.  The  patient  gave  a  history  of  a  miscarriage 
fourteen  weeks  before  admission  to  the  hospital  with  almost  continuous  uterine 
hemorrhage  since,  accompanied  with  the  passage  of  pieces  of  tissue.  She  com- 
plained on  admission  of  abdominal  pain,  fever,  and  chills.  The  general  examina- 
tion was  negative,  and  the  vaginal  examination  showed  an  enlarged,  tender,  retro- 
flexed  uterus  with  a  soft  cervix  and  patulous  os. 

Temperature  102°  to  104°  F.  Pulse  110.  Leukocytes  7500.  Urine  negative. 
Operation:  Curetment  of  uterus — small  amount  of  curetings.  The  fever  con- 
tinuing, a  Widal's  test  was  made,  which  was  positive,  and  rose  spots  appeared 
shortly  after. 

Diagnosis,  typhoid  fever. 

She  was  discharged  after  the  usual  course  of  the  disease. 

4.  In  a  fourth  case  the  typhoid  fever  developed  as  the  patient  was  convalescing 
from  an  acute  attack  of  pelvic  inflamrdation  of  gonorrheal  origin.  There  were 
numerous  intestinal  adhesions,  which  after  the  onset  of  typhoid  gave  rise  to  chronic 
intestinal  obstruction.  An  operation  to  relieve  the  obstruction  was  partially  suc- 
cessful. The  patient  died,  but  whether  of  the  typhoid  or  as  a  result  of  the  ob- 
struction was  not  determined. 


SYPHILIS.  73 

In  differentiating  typhoid  fever  from  suspected  inflammatory  affections  the 
leukocyte  count  is  of  the  utmost  vahie.  A  low  leukocyte  count  might  decide  the 
diagnosis  in  a  doubtful  case.  Widal's  test,  when  positive,  is  perhaps  the  most  im- 
portant sign  in  making  a  diagnosis.  Diarrhea,  the  rose  spots,  the  nature  of  the 
temperature  curve,  and  the  failure  to  find  any  lesion  in  the  genital,  urinary,  or 
pulmonary  tracts  are  likewise  of  much  value. 

In  those  patients  who  are  suffering  coincidently  with  typhoid  fever  and  some 
suppurative  gynecologic  disease  one  is  very  liable  to  overlook  the  former.  Many 
of  these  cases  are  sent  to  the  hospital  as  emergency  cases,  and  consequently  are  not, 
as  a  rule,  studied  as  carefully  as  they  should  be.  Only  the  most  painstaking  study 
of  the  case  and  the  employment  of  the  blood-count  and  the  Widal  test  will  enable 
one  to  arrive  at  a  correct  diagnosis. 

The  prognosis  in  typhoid  fever  patients  who  have  undergone  long  or  severe 
operations  is,  of  course,  much  worse  than  it  would  otherwise  be. 


SYPHILIS. 

The  lesions  of  tertiary  syphilis  are  the  causes  of  many  of  the  affections  which 
fall  into  the  hands  of  the  gynecologist  for  treatment.  A  large  percentage  of  the 
cases  of  stricture  of  the  rectum,  a  certain  proportion  of  those  of  rectovaginal  fis- 
tula, and  ulcerative  processes  connected  with  the  vulva,  vagina,  and  urethra  are 
the  result  of  the  second  or  third  stages  of  syphilis.  The  extreme  difficulty  in  curing 
syphilitic  fistulas  and  strictures  is  well  known,  and  their  treatment  is  given  in  other 
sections  in  this  book.  The  occurrence  of  the  secondary  lesions  of  syphilis  occasion- 
ally takes  place  after  operations  for  other  diseases.  It  is  not  infrequent  that  gon- 
orrhea and  syphilis  are  simultaneously  contracted  and  the  primary  syphilitic  lesions 
escape  notice.  The  secondary  lesions  may  in  consequence  make  their  appearance 
after  an  operation  for  an  abscess  of  Bartholin's  gland,  an  acute  salpingitis,  or  pelvic 
abscess.  The  symptoms  and  signs  of  syphilis  are  usually  so  unmistakable  that  the 
diagnosis  is  not  difficult.  There  is  a  manifestation  of  syphilis  which  is  extremely 
interesting  and  which  is  rarely  considered.  This  is  syphilitic  fever,  one  case  of 
which  came  under  my  observation  as  a  post-operative  complication.  The  case 
has  been  reported  in  full  by  Futcher.^  Following  an  operation  for  pelvic  inflamma- 
tion the  woman  had  an  elevation  of  temperature,  accompanied  by  fever  and  sweat- 
ing. The  case  at  first  sight  resembled  malaria.  The  blood,  however,  proved  to 
be  free  from  the  malarial  parasite,  and  it  was  only  when  the  secondary  eruption 
developed,  nearly  one  month  after  the  appearance  of  the  fever,  that  the  diagnosis 
was  made.  Syphilitic  fever  may  occur  at  various  periods  in  the  course  of  the  dis- 
ease. It  may  occur,  as  in  our  case,  three  or  four  weeks  before  the  secondary  skin 
eruption,  it  may  occur  with  or  immediately  precede  the  eruption,  or  it  may  occur  at 
any  time  during  the  course  of  the  secondary  or  tertiary  stages  of  the  disease.     The 

1  Futcher,  T.  B.:  "Syphilitic  Fever,  with  a  Report  of  Three  Cases,"  N.  Y.  Med.  Jour.,  June 
22,  1901,  1065-1069. 


74  COMPLICATIONS   FOLLOWING   OPERATIONS. 

occurrence  of  fever  of  obscure  origin  following  an  operation  should  make  one 
consider  syphilis  as  a  possible  cause.  The  absence  of  the  malarial  parasite  from 
the  blood  of  the  patient;  the  absence  of  a  leukocytosis;  the  negative  results  of 
Widal's  test  and  the  absence  of  other  signs  of  typhoid  fever;  the  failure  of  the  patient 
to  react  from  tuberculin  and  the  failure  to  find  a  tuberculous  lesion ;  and  the  absence 
of  a  focus  of  suppuration  to  account  for  the  fever  in  obscure  cases  should  cause 
one  to  suspect  syphilis.  A  history  of  syphilis,  the  presence  of  the  scar  of  the  pri- 
mary sore,  or  evidence  of  tertiary  syphilis  in  the  ^^scera  or  long  bones  would  justify 
in  such  cases  the  administration  of  mercury  and  iodid  of  potassium.  The  fever 
promptly  yields  to  these  remedies. 

HYSTERIA. 

This  disease  may  develop  during  convalescence  and  cause  much  anxiety  to 
those  upon  whom  the  care  of  the  patient  devolves.  "While  not  in  itself  dangerous, 
it  may  lead  to  an  incorrect  diagnosis  and  subject  the  patient  to  treatment  that  is 
hurtful.  The  mistake  wliich  is  more  frequently  made  is  in  regarding  some  serious 
affection  as  hysteria.  Cases  of  pulmonary  embolism,  nephritis,  insanity,  and 
other  serious  post-operative  affections  have  been  mistaken  for  hysteria.  It  would 
be  superfluous  to  go  into  the  symptoms  and  treatment,  but  I  would  warn  the  reader 
against  being  too  prone  to  consider  symptoms  wliich  arise  after  operation,  and  which 
cannot  readily  be  explained,  as  hysterical.  The  diagnosis  of  hysteria  should  be 
made  only  after  the  most  careful  examination  and  exclusion  of  other  more  serious 
affections, 

POST-OPERATIVE  NEURASTHENIA. 

Post-operative  neurasthenia  frequently  makes  its  appearance  before  the  patient 
leaves  the  surgeon's  care,  and  therefore  falls  under  the  head  of  complications 
following  operation.  As  in  post-operative  insanity,  the  predisposing  cause  is  a 
neuropathic  tendency  which  may  be  inherited,  or  which  may  be  acquired  by  over- 
work, worry,  exhausting  diseases,  the  use  of  stimulants  and  narcotics,  sexual  ex- 
cesses, dietetic  imprudences,  and  the  various  other  causes  wliich  are  supposed  to 
produce  neurasthenia.  The  exciting  causes  may  be  placed  in  two  large  classes: 
(1)  the  shock,  excitement,  worry,  fear,  exhaustion,  suppuration,  etc.,  which  are 
incident  to  operation;  and  (2)  the  disorders  due  to  the  artificial  menopause  pro- 
duced by  the  removal  of  the  ovaries,  uterus,  or  both  ovaries  and  uterus. 

The  cases  falling  under  the  first  of  these  groups  are  seen  as  often  after  opera- 
tions performed  by  the  general  surgeon  as  by  the  gynecologist,  and  bear  a  close 
resemblance  to  many  cases  of  traumatic  neurasthenia.  The  reader  is  referred  to 
text-books  on  the  practice  of  medicine  for  articles  upon  neurasthenia,  as  the  post- 
operative variety  of  the  affection  cannot  as  yet  be  differentiated  from  the  usual 
kinds. 

In  a  woman  whose  uterus,  ovaries,  or  both  uterus  and  ovaries  have  been  re- 
moved there  results  an  artificial  menopause,  and  the  disorders  which  occur  at 


POST-OPERATIVE    NEURASTHENIA.  75 

the  natural  change  of  Hfe  are  seen  here  at  times  in  an  exaggerated  degree.  In 
these  cases  the  cause  named  in  group  (1)  operate  also.  The  disorders  of  the  meno- 
pause artificially  produced  are  many  and  often  severe.  There  are  flashes  or  flushes 
of  heat,  palpitations,  hystero-neuroses,  and  physical  disturbances. 

The  flushes  come  on,  as  a  rule,  within  a  few  weeks  after  operation  and  persist 
for  periods  of  time  varying  from  a  few  months  to  several  years.  Their  intensity 
grows  less,  usually  in  a  few  months.  They  frequently  appear  every  forty  to  fifty 
minutes  while  the  patient  is  awake,  and  are  sometimes  preceded  by  a  slight  faint- 
ness,  chilly  sensations,  or  dizziness.  The  patient  feels  that  she  is  pale  and  that 
the  blood  is  leaving  the  surface  of  the  body.  This  is  followed  by  a  wave  of  heat 
which  rushes  over  the  surface  of  the  body,  particularly  the  face  and  neck,  causing 
burning,  tingling,  and  flushing  of  these  parts,  and  this  is  succeeded  by  sweating. 
The  patient  may  complain  of  her  heart  beating  very  forcibly,  the  thumping  of  which 
she  can  hear.  The  flushes  are  nervous  phenomena,  the  vascular  system  responding 
to  the  same  sort  of  stimulus  which  causes  blushing. 

Palpitation  and  tachycardia,  which  may  or  may  not  accompany  the  flushes 
or  be  seen-  independently,  are  likewise  due  to  a  disturbed  nervous  system. 

The  hystero-nervous  and  psychic  phenomena  are  those  of  other  forms  of  neu- 
rasthenia, but  are  frequently  seen  in  women  who  have  previously  been  free  from 
them. 

The  causes  of  the  climacteric  disturbances  are  not  at  all  well  understood.  The 
cessation  of  both  the  monthly  flow  and  the  internal  secretion  of  the  ovary  is  a 
probable  factor  in  producing  them.  The  disturbed  metabolism  which  results  from 
suddenly  causing  the  stoppage  of  a  monthly  loss  of  a  considerable  amount  of  blood, 
and  the  mental  efl^ect  produced  upon  the  patient  who  knows  that  her  organs  of 
procreation  have  been  removed,  must  both  act  deleteriously  upon  the  human  organ- 
ism. The  removal  of  the  ovaries,  according  to  the  belief  of  most  observers,  has 
more  to  do  with  the  production  of  the  climacteric  phenomena.  The  ovary  is  assumed 
to  have  a  secretion  of  its  own  whose  proper  regulation  is  necessary  for  the  good 
health  of  the  woman,  and  when  this  secretion  is  suddenly  stopped  there  occur  the 
symptoms  noted  at  the  menopause.  This  belief  has  so  firm  a  hold  in  the  minds  of 
certain  gynecologists  that  many  of  them  try  in  all  cases  to  leave  behind  at  least  a 
portion  of  one  ovary. 

The  treatment  of  post-operative  neurasthenia  in  general  is  that  of  other  forms 
of  the  disease.  Where  the  ovaries  have  been  removed  the  administration  of  ovarian 
extract  in  doses  of  2  to  5  grains  three  times  a  day  has  given  in  some  cases  very 
gratifying  results.  The  hot  flushes  have  in  some  reported  cases  ceased  in  forty- 
eight  hours  after  beginning  the  administration  of  the  drug.  No  disagreeable  after- 
effects of  the  remedy  have  been  noted.  In  estimating  the  therapeutic  value  of 
ovarian  extract  only  those  cases  should  be  considered  in  which  the  patient  is 
ignorant  of  the  nature  of  the  medicament;  otherwise  the  effects  noted  may  be  due 
to  psychotherapy.  (For  a  further  consideration  of  the  subject  see  Vol.  I,  pp. 
314-320.) 


76  COMPLICATIONS   FOLLOWING   OPERATIONS. 

POST-OPERATIVE  INSANITY. 

Insanity  following  gynecologic  operations  may  conveniently  be  divided  into 
two  classes:  (1)  Insanity  which  immediately  follows  operation  as  a  result  of  the 
excitement,  the  anesthetic,  nephritis,  infection,  etc.;  (2)  that  form  of  insanity 
which  follows  the  removal  of  the  ovaries  with  the  resulting  production  of  the  artifi- 
cial menopause.  The  gynecologist  has  to  deal  with  the  first  class,  in  which  the 
affection  comes  on  during  the  convalescence  of  the  patient  from  the  operation. 

The  removal  of  the  ovaries  may  produce  an  insanity  which  is  the  result  of  a 
premature  menopause.  Although  these  cases  are  of  extreme  interest  to  every 
gynecologist,  they  cannot  be  considered  as  complications  to  operation,  and  conse- 
quently will  not  be  treated  here,  and  the  term  will  be  applied  only  to  the  first  class. 

Following  our  7000  gynecologic  operations  there  have  been  twenty  cases  of 
insanity  which  developed  before  the  patients  left  the  hospital.  In  most  of  them 
the  mental  symptoms  developed  within  the  first  two  weeks,  four  showing  signs  of 
insanity  immediately  after  operation.  The  time  after  the  operation  at  which  the 
others  became  insane  varied  from  seven  days  to  five  weeks.  Dent  gives  the  time 
to  be  from  two  days  to  eight  weeks. 

The  causes  of  post-operative  insanity  may  be  divided  into  the  predisposing 
and  the  exciting.  "The  essential  prerequisite  for  its  development  must  be  in  all 
cases  a  neurotic  organization  predisposed  either  from  hereditary  taint  or  from  ac- 
quired nervous  weakness  to  take  on  diseased  action  in  consequence  of  any  actively 
disturbing  influence."^  The  majority  of  women  in  whom  insanity  develops  sub- 
sequent to  operation  give  a  history  of  previous  nervousness  and  hysteria,  and  in 
many  cases  the  operation  is  performed  for  the  relief  of  symptoms  due  to  this  ner- 
vous condition. 

The  exciting  causes  are:  excitement  and  apprehension  prior  to  operation,  the 
prolonged  use  of  the  anesthetic,  and  the  subsequent  nausea  and  vomiting,  shock 
and  weakness,  loss  of  blood,  nephritis  or  some  functional  disturbance  of  the  kidneys, 
infection,  autointoxication  from  the  intestinal  canal,  and  the  action  of  certain  drugs. 
In  our  cases  the  excitement,  etc.,  prior  to  operation  seemed  to  be  the  most  important 
factor.  In  at  least  nine  of  the  cases  the  operation  was  simple,  the  time  of  anesthesia 
short,  there  was  no  evidence  of  infection,  there  was  no  excessive  hemorrhage,  no 
shock,  and  no  poisoning  by  drugs.  The  operations  were  as  follows:  Hystero- 
salpingo-oophorectomy,  4  cases;  hysterectomy  for  carcinoma,  3  cases;  curetment 
for  carcinoma,  2  cases;  perineorrhaphy  and  suspension  of  the  uterus,  trachelor- 
rhaphy, fixation  of  the  kidney,  removal  of  a  vesical  calculus,  and  excision  of  a 
syphilitic  stricture  of  the  rectum,  one  case  each.  In  one  case  of  hysteromyomec- 
tomy  there  was  an  intimate  connection  between  the  development  of  the  insanity 
and  of  nephritis,  the  appearance  of  albviminuria  and  casts  in  the  urine  occurring 
with  that  of  the  mental  symptoms  and  likewise  disappearing  with  them. 

^  Hurd,  H.  M.:  "Post-operative  Insanities  and  Undetected  Tendencies  to  Mental  Disease," 
Am.  Jour.  Obst.,  N.  Y.,  1899,  xxxix,  331. 


POST-OPERATIVE   INSANITY.  77 

Iodoform  is  said  to  be  the  cause  of  post-operative  insanity  quite  frequently. 
Atropin,  eserin,  salicylic  acid,  and  the  salicylates  are  also  supposed  to  be  causes, 
while  foreign  bodies,  as  drainage-tubes,  etc.,  have  apparently  been  the  cause  of 
persistent  insanity. 

The  prognosis,  according  to  most  authorities,  is  fairly  good,  rather  more  than 
half  of  the  cases  recovering  entirely.  A  considerable  proportion  recover  within  a 
few  weeks,  and  most  of  the  others  which  have  a  favorable  termination  within  six 
months. 

There  is  no  especial  form  of  mental  disturbance  to  which  the  term  post-operative 
insanity  can  be  applied.  Most  cases  belong  to  the  type  known  as  confusional 
insanity.  In  this  class  of  cases  insomnia,  headache,  irritability,  and  restlessness 
may  precede  the  attack.  During  the  attack  the  patients  are  generally  very  talka- 
tive, frequently  repeating  in  succession  a  number  of  words  which  rhyme.  They 
may  have  hallucinations  or  illusions,  and  are,  at  times,  extremely  restless,  continu- 
ally trying  to  get  out  of  bed  and  to  tear  off  their  bandages  or  clothing.  At  other 
times  they  are  apathetic,  quiet,  pay  little  attention  to  what  is  going  on  around  them, 
and  in  some  instances  they  sink  into  a  stupor.  The  most  prominent  feature  is  the 
cloudy  mental  condition  of  the  patient,  who  recognizes  neither  her  friends  nor 
surroundings.  There  is  generally  a  temperature  of  100°  to  101°  F.,  the  tongue  is 
coated,  there  is  anorexia,  or  there  may  be  refusal  of  food. 

Acute  mania,  melancholia,  and  other  forms  of  insanity  may  develop  after  opera- 
tion. 

The  treatment  of  the  condition  properly  belongs  to  the  alienist.  Until  the 
danger  of  tearing  open  the  wound  is  past  and  the  patient  can  be  safely  conveyed  to  a 
suitable  institution,  she  should  be  confined  to  bed,  forcible  means  being  used,  if 
necessary.  Due  attention  should  be  paid  to  the  proper  feeding.  Nourishing,  easily 
digested  food  should  be  given  in  liberal  quantities,  and,  if  resistance  to  its  proper 
administration  be  encountered,  enforced  feeding  should  be  resorted  to.  To  induce 
rest  the  bromids,  either  alone  or  combined  with  chloral,  are  recommended.  Hyos- 
cyamus  is  also  recommended.  Warm  baths  or  sponges  are  soothing  and  tend 
to  produce  sleep.  In  cases  where  there  are  evidences  of  kidney  disease,  diuretics, 
diaphoretics,  and  salines  are  indicated.  The  proper  regulation  of  the  bowels 
should  be  attended  to  and  strict  rules  with  regard  to  cleanliness  enforced.  The 
latter  is  very  necessary,  as  with  the  involuntary  passage  of  urine  and  feces  bed- 
sores and  local  infections  are  apt  to  result. 

The  advisibility  of  operating  upon  patients  for  the  effect  of  mental  impres- 
sion is  constantly  coming  forward.  There  is  a  prevalent  idea  among  the  laity  and 
many  of  the  medical  profession  that  where  a  woman  complains  of  vague  and  indefi- 
nite pains,  nervousness,  etc.,  the  origin  of  the  symptoms  is  in  the  genitalia,  and  many 
patients  have  the  idea  fixed  firmly  in  their  minds  that  an  operation  is  necessary  to 
cure  them.  These  cases  are  rarely  benefited  by  an  operation  and  are  usually  made 
worse.  The  most  difficult  cases  to  deal  with  are  those  who  have  slight  abnormali- 
ties and  in  whom  it  is  possible  that  the  symptoms  are  indeed  due  to  this  condition. 


78  COMPLICATIONS   FOLLOWING   OPERATIONS. 

Examples  of  such  cases  are  slight  retroversions  of  the  uterus  in  nulliparous  women, 
certain  forms  of  dysmenorrhea,  movable  kidney,  etc.  In  all  such  cases  the  ten- 
dencies to  mental  disease  should  be  carefully  considered,  and  the  rule  of  the  surgeon 
should  be  to  operate  only  in  those  cases  where  actual  disease  is  present  which  there 
is  a  probability  of  curing  by  operation.  (For  a  further  consideration  of  this  subject 
see  Vol.  I,  pp.  314-320.) 


PROLAPSE  OF  THE  FALLOPIAN  TUBE. 
After  vaginal  hysterectomy  or  other  operations  where  the  vault  of  the  vagina 
is  freely  opened  and  the  tubes  are  not  removed,  the  fimbriated  ends  occasionally 
fall  down  into  the  opening  and  become  fixed  in  this  position  by  adhesions  and  scar 
tissue.  The  condition  may  give  rise  to  a  mistake  in  diagnosis  in  cases  of  hysterec- 
tomy for  carcinoma  of  the  uterus,  the  fimbriae  being  mistaken  for  a  recurrence  of 
the  disease.  The  end  of  the  tube  also  resembles  very  closely  fresh  granulation  tissue. 
In  either  case  the  mistake  might  subject  the  patient  to  unnecessary  alarm  and 
treatment.  A  histologic  examination  of  the  tissue  is  necessary  to  make  a  positive 
diagnosis.  Two  cases  of  the  kind  have  occurred  in  the  Johns  Hopkins  Hospital. 
Usually,  treatment  is  not  necessary. 


CHAPTER  XXVII. 

CESAREAN  SECTION  AND  PORRO-CESAREAN  SECTION. 
By  J.  F.  W.  Ross,  M.D. 

By  Cesarean  section  is  meant  the  removal  of  the  fetus  from  the  mother  by 
making  an  opening  through  the  abdominal  or  vaginal  walls  and  an  incision  into 
the  uterus. 

Porro-Cesarean  section  means  the  abdominal  removal  of  the  body  of  the  preg- 
nant uterus — the  pregnancy  being  near  or  at  term.  This  title  has  been  made  to 
apply  to  amputation  of  the  uterus.  There  is  no  term,  as  yet  coined,  to  apply  to  the 
total  removal  of  the  pregnant  uterus. 

If  Greig  Smith's  definition,  "that  Cesarean  section  means  the  removal  of  the 
child  from  the  mother  who  fails  to  deliver  it,"  is  adopted,  it  must  necessarily  include 
ectopic  gestation. 

History. — Long  before  the  operation  had  been  performed  on  the  living  woman 
it  had  been  recommended  in  cases  in  which  women  died  undelivered.  Many  cele- 
brated men  are  said  to  have  been  brought  into  the  world  in  this  way. 

The  lex  regis  of  Numa  Pompilius  distinctly  ordered  that  no  woman  with  child 
should  be  interred  until  after  the  abdominal  cavity  had  been  opened.  This  law 
still  exists  in  the  Roman  Church.  The  original  idea  of  it  was  to  rescue  the  child 
in  order  that  it  might  be  baptized  before  life  became  extinct. 

The  precise  period  at  which  the  operation  of  Cesarean  section  was  first  performed 
on  the  living  woman  remains  undetermined.  In  1581  Roussett  published  a  mono- 
graph upon  the  subject.  About  this  time  it  appears  that  the  operation  was  very 
successfully  performed,  and  many  operators  were  emboldened  to  perform  it  without 
the  proper  indications.  We  are  told  that  it  became  almost,  as  common  as  blood- 
letting in  Italy.  Soon  a  reaction  set  in  and  the  operation  fell  into  disrepute.  The 
results  were  not  satisfactory  and  the  procedure  was  looked  upon  with  anything 
but  favor.  After  a  time  fresh  proofs  were  brought  forward  to  show  that  it  might 
be  successful  if  performed  by  skilled  hands.  No  doubt  the  advantages  and  dis- 
advantages were  greatly  exaggerated  during  the  whole  of  the  seventeenth  century. 
The  maternal  mortality  was  so  great  that  the  operation  was  condemned  until, 
in  1876,  Porro  introduced  his  operation  of  Cesarean  section  accompanied  by  ampu- 
tation of  the  uterus.  Statistics  showed  that  this  was  a  very  successful  procedure, 
and  it  made  a  much  more  favorable  showing  than  the  operation  of  Cesarean  section 
in  which  the  uterus  was  left  behind. 

Sanger,  of  Leipzig,  now  insisted  that  the  suturing  of  the  uterine  wall  was  essen- 
tial, and  after  careful  suturing  was  carried  out  the  results  were  much  better. 

79 


80  CESAREAN    SECTION   AND    PORRO-CESAREAN   SECTION. 

Isolated  cases  are  reported  in  which  the  operation  was  performed  carelessly 
without  asepsis  or  anesthetics;  some  were  successful.  Harris  tells  us  that  in  Ohio  a 
patient  made  a  good  recovery  after  a  Cesarean  section  had  been  performed  by  the 
doctor  in  charge  with  only  the  assistance  of  two  women  and  under  such  conditions/ 

Probably  the  earliest  operation  performed  upon  the  living  woman  was  done 
about  the  year  1500  by  Jakob  Nufer,  in  the  Canton  of  Thurgau.  He  was  a  gelder 
and  a  spayer  of  cattle.  His  wife  had  been  in  labor  for  some  time,  and  after  those 
in  attendance  considered  the  case  hopeless  he  opened  her  abdomen  and  delivered 
the  child.  Strange  to  say,  she  recovered  from  the  operation  and  gave  birth  to  several 
other  children  at  later  periods.     The  truth  of  this  story  is  doubted. 

According  to  some  authors  the  operation  has  been  successfully  performed  by 
midwives.^ 

Women  have  performed  Cesarean  section  upon  themselves.  The  operation  has 
been  accidentally  performed  upon  women  far  advanced  in  pregnancy  by  rips  from 
the  horns  of  cattle.  Harris^  says  that  six  women  in  one  hundred  and  nineteen  years 
performed  Cesarean  section  upon  themselves  and  that  of  eleven  women  ripped 
open  by  horned  animals,  eight  escaped  death.* 

Many  of  the  uncivilized  nations,  the  inhabitants  of  Uganda  and  Central  Africa, 
are  known  to  have  performed  Cesarean  section.^  Such  operations  are  also  known 
to  have  resulted  favorably  to  both  mother  and  child.  Palm  wine  was  the  fluid  used 
for  washing  the  abdomen  of  the  patient  and  the  hands  of  the  operator.  The  abdom- 
inal wound  was  closed  by  long  pins  just  as  it  was  closed  by  the  older  operators 
among  civilized  nations.  The  sutures  were  placed  over  the  pins  in  the  figure-of-8 
as  in  the  operation  for  harelip. 

Godson  states  that  for  over  one  hundred  years  the  operation  was  performed 
without  a  single  success  in  Vienna,  and  that  the  same  was  true  in  Paris.  Chiaria, 
of  Milan,  is  credited  with  sixty-two  operations  and  three  recoveries. 

The  results  obtained  in  former  times  are  now  of  historical  importance  only,  and 
the  operation  has  taken  its  place  among  the  most  successful  of  surgical  procedures. 
American  surgeons  have  done  much  to  place  the  operation  in  this  position. 

Conditions  for  Which  the  Operation  May  be  Done. — There  are  five  opera- 
tions which  may  be  considered.  They  are  Cesarean  section,  Porro-Cesarean  section, 
induction  of  premature  labor,  symphysiotomy,  and  craniotomy.  Each  has  its  indi- 
cations and  each  has  its  contraindications. 

^  Richmond,  John  L.:  "History  of  a  Successful  Case  of  Caesarean  Operation,"  Western  Jour. 
Med.  and  Phys.  Sciences,  1830,  vol.  iii,  p.  485. 

^  "Edinburgh  Essays,"  vol.  v,  p.  439.  Burroughs,  J.  J.:  "Csesarean  Section  Post-mortem — 
Successful  Delivery  of  a  Living  Fetus,"  New  Orleans  Med.  and  Surg.  Jour.,  vol.  xi,  p.  427.  Dubrac, 
F.:  "Etude  uncas  de  responsibiUte  medicale,"  Annales  D'  Hygiene  PubUques,  Tome  ix,  3s.  1883, 
p. 108. 

3  Harris,  Robert  P.:  "Six  Self-inflicted  Csesarean  Operations  with  Recovery  in  Five  Cases," 
Amer.  Jour.  Med.  Sci.,  Feb.,  1888,  p.  150. 

*  Harris,  Robert  P.:  "Cattle-horn  Lacerations  of  the  Abdomen  and  Uterus  in  Pregnant 
Women,"  Amer.  Jour.  Obst.,  July,  1887,  vol.  xx,  p.  673,  and  pp.  103.3-36. 

5  Felkin,  Robert  W.:  "Notes  on  Labor  in  Central  Africa,"  Edinburgh  Med.  Jour.,  April,  1884, 
pp. 922-930. 


CONDITIONS    FOR    WHICH    CESAREAN   SECTION    MAY    BE   DONE. 


81 


Cesarean  section  must  be  considered  in  two  senses :  first,  when  it  is  the  operation 
of  election;  and,  secondly,  when  the  indications  for  it  are  absolute.  Great  narrow- 
ing of  the  pelvis  is  an  absolute  indication  for  the  performance  of  either  the  Cesar- 
ean or  Porro-Cesarean  section.  (Fig.  406.)  In  all  cases  in  which  the  narrowing  of 
the  pelvis  exists  it  should  be  discovered  before  labor.  An  examination  of  the 
patient  would  convince  the  physician  that  delivery  in  the  ordinary  way  would  be 
impossible  or  extremely  difficult.  He  should  govern  himself  accordingly  and  have 
the  patient  so  placed  that  she  would  be 
most  favorably  situated  whatever  method 
of  procedure  might  be  finally  adopted  to 
deliver  her. 

An  easy  method  of  remembering  pel- 
vic measurements  is  to  recall  that  there 
is  a  difference  of  an  inch  between  the  con- 
jugate, or  the  antero-posterior  diameter, 
and  the  transverse  diameter,  and  that 
for  all  practical  purposes  the  conjugate 
or  antero-posterior  is  4^  inches  and  the 
transverse  5j.  We  may  say,  therefore, 
that  a  measurement  of  3^  inches  (8.5  cm.) 
in  the  conjugate  is  sure  to  offer  an  obstacle 
that  may  result  unfavorably  to  both  mother 
and  child.  If  the  child's  head  is  so  much 
diminished  in  size  as  to  offset  the  narrow- 
ing of  the  pelvic  measurements,  delivery 
may,  perhaps,  be  accomplished  without 
much  difficulty.  This  variation  of  the 
normal  conditions  presents  features  of 
much  interest  and  demonstrates  practi- 
cally that  pelvimetry  alone,  in  many  cases, 
is  of  very  little  use  at  the  bedside — it  must 
be  valued  in  connection  with  the  size  of 
the  child's  head. 

It  seems  rather  absurd  to  endeavor  to 
settle  these  questions  by  mere  measure- 
ment of  inches  or  centimeters,  because  it  is  impossible  for  us  to  estimate  the  varia- 
tions that  may  occur  in  both  the  size  and  the  consistency  of  the  fetal  head.  When 
the  indications  for  Cesarean  section  are  absolute  (5  to  6  cm.),  it  is  unnecessary 
to  discuss  symphysiotomy  or  craniotomy,  and  scarcely  wise  to  discuss  the  induction 
of  premature  labor.  Symphysiotomy  will  not  give  room  enough  through  which  to 
dehver  a  living  child;  craniotomy  cannot  for  a  moment  be  considered  as  the 
child  is  living,  for  today  this  operation  should  not  be  performed  upon  the  living 
child.     If  the  patient  is  exhausted  by  long  labor,  the  maternal   mortality  after 

VOL.  II — 6 


Fig.  406. — Achondroplastic  Dwarf.     Cesarean 
Section;  Recovery  (J.  F.  W.  Ross). 


82  CESAREAN    SECTION   AND    PORRO-CESAREAN    SECTION. 

Cesarean  section  is  certainly  no  greater  than  that  after  craniotomy,  and  in  the  one 
case  the  child  can  be  saved  alive  and  in  the  other  its  life  is  destroyed. 

If  the  patient  has  a  very  much  contracted  pelvis,  with  a  conjugate,  say,  of  three 
inches  (7.5  cm.),  and  is  anxious  to  bear  a  living  child,  the  question  arises  whether 
it  is  possible  to  deliver  her  prematurely  and  save  the  child.  The  premature  con- 
dition of  the  fetus  endangers  its  life,  though  it  may  render  its  delivery  possible. 
Under  such  circumstances  it  is  very  difficult  to  choose  the  right  time  at  which  to 
induce  labor.  If  induced  at  too  early  a  period,  the  life  of  the  fetus  is  still  further 
endangered;  if  induced  at  too  late  a  period,  a  difficult  delivery  must  necessarily 
endanger  its  life.  By  modern  Cesarean  section  the  life  of  the  fetus  will  certainly 
be  better  insured,  while  the  danger  to  the  mother  should  not  be  much,  if  at  all, 
increased. 

Such  results  as  those  recorded  by  Reynolds,^  of  cases  of  Cesarean  section  known 
to  him  personally,  in  which  there  were  thirty  recoveries  in  thirty  cases,  must 
encourage  us  to  perform  this  operation  more  frequently  than  we  have  been 
accustomed  to  do  in  the  past.  We  must  remember,  however,  that  to  obtain  such 
results,  it  is  of  vital  importance  that  the  operation  should  be  undertaken  early, 
and  that  the  operator  must  be  thoroughly  familiar  with  every  detail.  Cesarean 
section  must  not  be  a  last  surgical  resource  to  effect  the  delivery  of  the  mother. 
It  must  be  a  conservative  procedure  to  save  the  lives  of  both  mother  and  child. 

If  we  look  carefully  into  the  question  of  the  mortality  to  the  mother  from  Cesa- 
rean section  at  the  present  time  and  under  the  most  favorable  circumstances,  per- 
formed by  experienced  operators,  we  must  be  convinced  that  the  mortality  is  not 
much  higher  than  that  from  oophorectomy,  while  the  mortality  to  the  children 
is  nil.  The  mortality  to  the  mother  from  severe  forceps  delivery  is  from  1  to  2 
per  cent.,  while  the  mortality  to  the  children  is  large,  namely,  from  25  to  30  per 
cent. 

The  modern  German  statistics,  when  analyzed,  teach  the  same  lessons.  To 
estimate  the  real  value  and  danger  of  the  operation  the  women  operated  upon  in 
good  condition  must  be  separated  from  those  already  exhausted  or  septic  upon 
whom  emergency  operations  were  done.  Olshausen^  reports  ninety-one  cases  of 
Cesarean  section  for  contracted  pelvis,  with  nine  deaths.  He  did  sixty-five  of  these 
operations  himself,  and  in  this  series  had  three  deaths — a  mortality  of  4.6  per  cent. 
The  ninety-one  operations  were  upon  women  admitted  seriatim  to  an  obstetrical 
clinic,  and  included  emergency  cases. 

Neumann^  records  one  hundred  and  seventy  Cesarean  sections  in  Schauta's 
clinic,  done  for  every  variety  of  indication,  with  a  total  mortality  of  fourteen— 8  per 
cent. 

1  Reynolds,  Edward:  "The  Cesarean  versus  Fetal  Mortality,"  Amer.  Jour,  of  Obst.,  1898, 
vol.  xxxvii,  No.  6,  p.  721,  and  personal  communication. 

^'Olshausen,  R.:  "Zur  Lehre  von  Kaiserschnitt,"  Zentralbl.  f.  Gyniik.,  1,  1906. 

3  Neumann,  Julius:  "Die  Sectio  Caesarea  am  der  Klinik  Schauta,"  Zentralb.  f.  Gynak.,  29, 
1905,  913. 


CONDITIONS    FOR    WHICH    CESAREAN   SECTION    MAY   BE    DONE.  83 

Leopold^  reports  one  hundred  cases,  seventy-one  of  which  were  Cesarean  sec- 
tions and  twenty-nine  Porro  operations,  with  a  total  mortahty  of  ten — 10  per  cent. 

Von  Braim-FernwakP  reports  seventy-four  Cesarean  sections  from  Braun's 
chnic.  There  were  six  maternal  deaths,  or  8.1  per  cent,  mortality.  He  also  reports 
that  Zweifel  has  had  seventy-six  conservative  Cesarean  sections  with  one  death. 
The  patient  that  died  was  septic  when  operated  upon  and,  therefore,  should  be 
excluded  in  estimating  the  mortality  of  the  elective  Cesarean  sections.  Hence,  in 
Zweifel's  hands,  the  operation  has  been  without  mortality. 

An  analysis  of  Braun's  cases  shows  that  five  of  the  deaths  were  due  to  infec- 
tion before  operation  or  to  delay  in  operating  or  to  complicating  diseases,  so  that 
the  patients  were  exhausted  or  in  bad  condition.  Norris,^  quoting  Pinard's  state- 
ment at  the  International  Congress  at  Amsterdam  in  1897,  says:  ''A  resume  of 
the  statistics  of  Leopold,  Olshausen,  and  Zweifel  shows  a  mortality  of  5.8  per  cent, 
for  the  conservative  Cesarean  section,  and  of  3.7  per  cent,  for  the  Porro  operation." 

When  the  indications  are  not  absolute  we  are  placed  in  a  very  difficult  position. 
The  question  we  have  then  to  answer  is.  What  will  take  place  in  a  case  in 
which  the  pelvic  measurements  are  diminished  ?  If  the  woman  has  had  repeated 
difficult  labors,  with  the  death  of  the  child  in  each  case.  Cesarean  section  offers  a 
ready  and  safe  means  of  delivering  a  living  child.  The  patient  can  make  her  own 
choice  after  the  matter  has  been  put  fairly  before  her.  The  question  can  be  dis- 
cussed with  her  before  labor.  She  must  be  told  everything  that  is  favorable,  and 
that  the  chances  are  that  she  will  have  a  living  child.  Also  none  of  the  risks  should 
be  hidden  from  her.  She  should  not  be  called  upon  to  judge  as  to  the  relative  merits 
of  the  various  operations,  but  should  consent  to  what  appears  to  be,  in  the  judgment 
of  her  attending  physician  or  physicians,  the  wisest  course  of  procedure.  Rey- 
nolds says  that  when  a  practitioner  is  consulted  by  a  patient  in  whom  a  previous 
labor  has  resulted  in  the  delivery  of  a  stillborn  child  by  high  forceps  or  version, 
performed  for  simple  delay,  that  is,  in  the  presence  of  obstetric  emergencies,  the 
pelvis  should  be  measured  and  the  question  of  the  performance  of  Cesarean  section 
should  be  settled  in  advance  of  labor  upon  the  rides  laid  down.^ 

One  would  not  feel  so  much  in  favor  of  Cesarean  section  when  only  one  labor 
had  resulted  in  the  death  of  the  fetus,  as  when  there  had  been  two  such  labors. 
We  all  know  that  a  primiparous  woman  may  have  a  difficult  forceps  delivery,  may 
lose  her  child,  and  may  subsequently  bear  children  after  labors  that  are  neither 
difficult  nor  instrumental.  The  characteristics  of  the  fetal  head  do  not  appear  to 
be  different  in  many  of  these  cases,  so  that  there  must  be  some  other  element  that 

^Corner:  "50  Kaiserschnitte  wegen  Beckenge,"  Arbeiten  a.  d.  Kgl.  Frauenklinik  zu  Dresden, 
Bd.  i,  1893;  Leopold  u.  Naake:  "Ueber  100  Sectiones-Caesarea,"  Archiv.  f.  Gyniik.,  Bd.lvi,  Hft. 
1,  p.  1. 

^  Von  Braun-Fernwald,  Richard:  "Ueber  die  in  denLetzten  10  Jahren  ausgefuhrten  Sectiones 
Caesareae,"  Arch.  f.  Gyniik.,  hx,  320. 

^Norris,  Richard  C:  "Progressive  Medicine,"  Sept.,  1900,  381. 

*  Reynolds,  Edward:  "The  Cesarean  versus  Fetal  Mortahty,"  Amer.  Jour,  of  Obst.,  1898, 
vol.  xxxvii.  No.  6,  p.  729. 


84  CESAREAN   SECTION   AND    PORRO-CESAREAN   SECTION. 

facilitates  a  second  delivery;  the  pelvis  has  become  more  roomy.  I  am  afraid  that 
the  advocate  of  Cesarean  section,  under  such  circumstances,  will  frequently  be 
discredited  by  the  fortunate  and  unexpected  delivery  of  these  women  in  the  ordinary 
way.  For  this  reason,  it  is  wise  to  place  such  women  in  a  suitable  environment, 
and  only  resort  to  Cesarean  section  after  a  test  of  the  natural  forces  of  labor.  If, 
on  the  other  hand,  two  or  three  labors  have  resulted  in  the  delivery  of  stillborn 
children  by  high  forceps  or  version  performed  for  simple  delay,  we  can  then  rest 
assured  that  the  obstruction  continues  to  be  equally  great  and  that  there  is  no  chance 
for  the  delivery  of  a  living  child  on  a  future  occasion,  unless  by  the  induction  of 
premature  labor,  symphysiotomy,  or  Cesarean  section. 

It  is  a  well-known  fact  that  many  infants  are  seriously  injured  for  life  as  a  con- 
sequence of  a  severe  delivery  per  vias  naturalis.  Even  though  they  are  delivered  by 
symphysiotomy,  these  infants  may  be  damaged. 

In  considering  the  operation  of  symphysiotomy,  the  amount  of  room  to  be 
gained  and  the  subsequent  convalescence  of  the  patient  must  be  taken  into  careful 
consideration.  A  patient  will  regain  health  and  strength  more  rapidly,  perhaps, 
after  the  performance  of  a  Cesarean  section  than  after  the  operation  of  symphy- 
siotomy. A  considerable  weakness  of  the  symphysis  may  exist  for  some  time.  A 
comparison  of  the  two  operations  must,  therefore,  be  instituted  in  order  that  we  may 
arrive  at  a  correct  conclusion.  In  the  hands  of  a  skilled  surgeon  the  one  operation 
is  almost  as  difficult  as  the  other,  though,  perhaps,  the  operation  of  symphysiotomy 
requires  less  preliminary  preparation.  One  very  important  point  to  be  borne  in 
mind  is  the  fact  that  it  is  difficult  to  say  that  the  amount  of  room  gained  by  the 
performance  of  symphysiotomy  will  be  ample  to  permit  of  the  delivery  of  the  fetus 
without  injury  to  the  soft  parts  of  the  mother. 

Zinke^  mentions  one  case  in  which  it  was  necessary  to  perform  Cesarean  section 
after  an  effort  had  been  made  to  deliver  the  woman  by  symphysiotomy.  This 
shows  the  difficulty  to  be  met  with  in  accurately  determining  whether  the  increased 
room  will  permit  of  the  passage  of  the  child  or  not.  The  same  author  also  says 
that  in  several  instances  Cesarean  section  had  to  be  substituted  for  symphysiotomy 
on  account  of  the  ossification  of  the  joint.  This  difficulty  may  be  overcome  by  using 
a  chain-saw. 

With  a  conjugate  diameter  of  3^  inches,  one  mother  out  of  thirteen  died,  and 
with  a  conjugate  of  2|  inches,  four  out  of  fifteen  died  after  the  performance  of 
symphysiotomy.  Of  all  children  delivered  through  a  conjugate  of  3^  inches, 
four  out  of  thirteen  died,  and  through  a  conjugate  of  2f  inches,  two  out  of  fifteen 
died.  So  that  we  see  that  even  with  a  conjugate  of  3j  inches,  modern  Cesarean 
section  ought  to  give  a  lower  fetal  mortality  than  symphysiotomy.  As  with  Cesar- 
ean section  so  with  symphysiotomy,  the  operation  is  frequently  not  done  until  the 
patient  is  in  articido  mortis.  The  high  maternal  mortality  cannot  be  laid  at  the 
door  of  the  operation  itself.     But  the  infant  mortality  from  the  operations  also 

'  Zinke,  E.  Gustav:  "Symphysiotomy  vs.  Embryotomy  upon  the  Ijiving,"  Ohio  Med.  Jour., 
vol.  vi,  1895,  p.  73. 


CONDITIONS    FOR   WHICH    CESAREAN   SECTION   MAY   BE   DONE.  85 

remains  high.  With  Cesarean  section  the  infant  mortaUty  is  hkely  to  be 
reduced. 

Reynolds  conckides  that  he  would  use  symphysiotomy  in  cases  in  which  we 
have  a  moderately  contracted  pelvis  in  a  woman  not  previously  healthy,  and  in 
cases  in  which  the  mother  is  exhausted  by  long  labor.  In  the  latter,  if  symphysiotomy 
fails  to  give  sufficient  room,  we  still  have  another  resource,  but  the  chances  are 
that  in  the  efforts  to  deliver  the  woman  the  life  of  the  child  will  be  sacrificed.  If 
this  occurs,  we  might  just  as  well  have  performed  craniotomy  at  the  outset.  But 
why  allow  the  woman  to  arrive  at  this  condition?  It  is  easy  to  sit  in  one's  arm- 
chair and  argue;  it  is  inore  difficult  to  act  for  the  best  at  the  bedside. 

The  patient  is  in  labor,  the  cervix  dilates,  the  pelvic  measurements  show  a  not 
very  great  diminution  from  the  normal;  the  child  does  not  come  down,  and  we  natu- 
rally proceed  to  assist  in  the  delivery  by  a  forceps  operation.  When  the  forceps 
are  placed  it  is  necessary  that  they  be  pulled  down,  and  unless  they  are  pulled 
upon  vigorously,  we  might  better  have  left  them  unapplied.  We  are  now  enabled 
to  determine  the  compressibility  of  the  head,  and  from  a  slight  traction  we  proceed 
to  apply  more  force.  The  forceps  begins  to  slip  and  perspiration  to  bathe  the  opera- 
tor. The  progress  may  be  very  slow.  Finally,  when  the  forceps  fail  to  deliver  a 
consultation  is  called  for.  Unless  the  consultant  has  every  confidence  in  the 
doctor  in  charge,  he  may  desire  to  apply  the  forceps  himself  and  make  his  own 
attempt  to  deliver  the  patient.  When  he  has  done  so  the  patient  is,  in  all  probability, 
much  exhausted,  the  soft  parts  bruised,  and  the  fetus  dead.  If  the  operator  is 
certain  that  the  fetus  is  dead,  the  head  is  now  perforated  and  the  child  delivered, 
and  he  feels  thankful  that  he  has  succeeded  in  saving  the  life  of  the  mother. 

When  we  look  back  over  such  a  case  we  naturally  ask  ourselves,  At  what  point 
should  pelvic  delivery  have  ceased  and  Cesarean  section  (abdominal)  have  begun  ? 
It  is  easy  for  us.to  review  such  a  case  and  to  criticize,  but  the  obstetrician  who  enters 
a  gentleman's  house,  and,  without  making  an  effort  to  deliver  his  wife,  tells  him 
that  she  must  be  delivered  by  Cesarean  section,  is  liable  to  be  discharged  unless 
he  is  fortified  by  a  very  considerable  reputation  in  this  particular  branch.  Pelvic 
delivery  is  looked  upon  as  a  natural  procedure.  Cesarean  section  as  an  unnatural 
one.  When  it  is  rendered  a  safe  method  of  delivery  and  the  woman  is  able  to 
escape  the  pangs  of  labor,  many  of  the  difficulties  that  now  surround  the  attending 
obstetrician  will  disappear. 

But  no  matter  how  much  we  teach  or  how  much  we  argue,  cases  such  as  the  above 
will  continue  to  be  treated  in  exactly  the  same  manner  by  the  very  best  obstetri- 
cians. We  must  remember  that  there  is  the  danger  that  the  pendulum  will  swing 
too  far,  and  that  Cesarean  section  may  be  undertaken  in  cases  in  which  a  forceps 
delivery,  if  attempted,  could  be  carried  to  a  successful  issue.  Unless  the  patient 
is  practically  moribund.  Cesarean  section  should  not  be  undertaken  unless  the 
most  thorough  preparations  have  been  instituted  for  its  performance  and  proper 
assistance  has  been  secured. 

The  operation  has  been  performed  with  very  satisfactory  results  after  the  death 


86 


CESAREAN   SECTION   AND    PORRO-CESAREAN   SECTION. 


of  the  mother.  Villeneuve  says  that  in  five  such  cases  the  fetus  remained  in  utero 
for  from  five  minutes  to  half  an  hour  after  the  mother's  death.  The  fetus  is  not 
very  Hkely  to  survive  if  left  longer  than  half  an  hour  in  utero.  It  has  been  claimed, 
however,  that  it  has  survived  much  longer.  It  is  a  well-known  fact  that  children 
have  been  put  aside  apparently  dead,  and  have  suddenly  astonished  the  attendants 
by  crying  out,  so  that  it  must  be  very  difficult  for  any  one  to  say  that  a  child  in  utero 

is  actually  dead  before  it  is  removed.  It 
is  unpleasant  to  think  that  the  body  of 
the  mother  should  be  the  coffin  of  the 
child.  It  is  always  better  that  the  woman 
should  be  delivered  even  after  death. 

Those    who     have    performed 


Fig.  407. — Myoma  of  the  Cervix  Uteri 
iNG  Delivery. 

Cesarean  section  will  be  most  reluctant  to  consent  to  the  induction  of  premature 
labor,  or  to  the  performance  of  the  operations  of  symphysiotomy  or  craniotomy. 
Our  first  duty  is  always  to  the  mother  when  the  question  of  operation  is  being 
considered.  The  chances  of  success  after  Cesarean  section  are  greater  if  the 
operation  is  performed  before  or  shortly  after  the  onset  of  labor. 

It  has  been  stated  that  the  poor  results  among  surgeons  are  due  to  lack  of  knowl- 
edge of  the  pelvic  measurements  on  the  part  of  the  attending  physicians.     This 


CONDITIONS    FOR    WHICH    CESAREAN    SECTION    MAY   BE   DONE. 


87 


may  be  true  to  a  certain  extent,  but  all  who  have  experience  with  pelvic  measure- 
ments know  that  it  is  difficult  to  obtain  measurements  made  by  different  obstet- 
ricians that  will  coincide. 

Cases  are  met  with  in  which  one  feels  satisfied  after  examination  that  there 
will  be  great  difficulty  in  labor;  measurements  are  made  to  confirm  this  view; 
the  patients  drift  away,  and  for  some  unknown  reason  are  delivered  with  but  little 
difficulty.  If  the  pelvic  brim  were  exactly  circular,  or  oval,  and  the  fetal  head 
were  always  equally  compressible,  we  could  then  rely  upon  pelvic  measurements. 


Fig.  408. — Ovarian  Cyst  Obstructing  Delivery. 


But  as  the  pelvic  brim  is  irregularly  shaped,  and  as  the  fetal  head  presents  varying 
degrees  of  compressibility,  pelvic  measurements  will  often  be  uncertain  guides. 
The  causes  of  dystocia  are  pelvic  deformities  and  obstruction  of  the  pelvis  by 
tumors  occurring  in  the  ovary  (Fig.  408),  the  cervix  uteri  (Fig.  407),  the  vaginal 
tissues  or  the  pelvic  bones  (Fig.  409).  Dystocia  has  followed  the  operation  of 
ventrofixation  in  numerous  cases.  The  pelvic  deformities  usually  enumerated  are 
rachitic  deformity,  kyphotic  pelvis,  oblique  pelvis,  dwarf  pelvis,  coxalgic  pelvis, 
and  anchylosed  pelvis. 


88  CESAREAN   SECTION   AND    PORRO-CESAREAN   SECTION. 

Noble^  relates  two  cases,  one  delivered  by  version  and  the  other  by  Porro- 
Cesarean  operation,  in  which  the  dystocia  was  produced  by  ventrofixation. 

Inflammatory  exudate  blocking  the  pelvis  has  also  caused  such  serious  dystocia 
that  Cesarean  section  was  performed.  Noble  relates  a  case  of  this  kind.  The 
pelvis  was  blocked  with  inflammatory  exudate  forming  a  tumor.  To  dehver  the 
child.  Cesarean  section  was  performed.  Subsequent  sloughing  took  place  and  a 
uterine  fistula  opening  on  the  front  of  the  abdomen  was  established.  This  fistula 
never  healed  soundly.  The  patient  again  became  pregnant  and  consulted  Noble 
about  the  thirty-third  week  of  pregnancy.  The  membranes  had  ruptured  and  the 
waters  were  coming  away  through  the  ventral  fistula  and  the  fistulous  opening  was 


Fig.  409. — Osteosarcoma   (a)  of  the  Sac- 
rum Obstructing  Delivery. 


dilating  under  the  influence  of  the  feeble  uterine  pains.  The  cervix  was  but  slightly 
dilated  and  in  the  center  of  a  mass  of  scar  tissue.  The  fetus  was  small  and  imma- 
ture. After  Cesarean  section  the  hemorrhage  could  not  be  controlled  in  the  usual 
way  on  account  of  the  intra-abdominal  fixation  of  the  uterus.  It  was,  therefore, 
inverted  through  the  wound  of  the  operation  so  that  the  assistant  could  grasp 
the  lower  uterine  segment  while  the  secundines  were  peeled  off.  Some  of  the  deep 
stitches  were  passed  through  both  uterine  and  abdominal  walls.  The  patient 
recovered  and  the  fistula  has  not  reformed. 

1  Noble,  Charles  P.:  "A  Clinical  Report  on  the  Course  of  Pregnancy  and  Labor  as  Influenced  by 
Suspensio  Uteri,"  Amer.  Gynec.  and  Obst.  Jour.,  Nov.,  1896,  p.  543. 


TIME    FOR    OPERATION.       TECHNIC.  89 

In  cases  in  which  fibroid  tumor  of  the  cervix  obstructs  the  pelvis  a  spontaneous 
delivery  sometimes  occurs  in  a  very  peculiar  manner.  The  tumor  is  flattened  and 
compressed  and  under  the  action  of  the  longitudinal  fibers  of  the  uterus  it  slips  up 
above  the  pelvic  brim,  the  fetus  comes  down,  and  delivery  is  effected  without  diffi- 
culty. To  the  observer  it  would  appear  that  such  a  delivery  would  be  impossible. 
Impacted  tumors  of  the  lower  uterine  segment  or  of  the  ovaries  that  cannot  be  re- 
placed under  anesthesia  require  Cesarean  section.  Injuries  that  have  produced 
contraction  may  necessitate  the  performance  of  Cesarean  section.  In  a  recent 
case  the  writer  performed  Cesarean  section  owing  to  the  presence  of  this 
condition.  As  a  girl  the  patient  had  slipped  upon  an  iron  hoop  when  going 
down-stairs,  cutting  the  soft  structures  about  the  perineum  and  producing  a  serious 
injury.  A  doctor  was  sent  for,  and  when  he  attempted  to  examine  her,  she  jumped 
out  of  a  first-story  window  and  fell  astride  of  a  wire  clothes-line,  cutting  through 
the  sphincter  ani  and  all  the  soft  tissues  down  to  the  coccyx  behind  and  the  pubic 
bone  in  front.  As  a  woman  she  became  pregnant,  and  shortly  after  labor  set  in, 
Cesarean  section  was  performed  and  mother  and  child  survived.  (Case  reported 
by  G.  E.  Smith,  of  Toronto.) 

Time  for  Operation. — Some  authorities  operate  before  labor  begins,  others 
wait  until  it  has  begun.  The  latter  think  that  in  this  way  better  drainage  is  secured 
through  the  dilated  cervix  and  that  the  risk  of  hemorrhage  is  not  so  great.  Drain- 
age, however,  can  be  easily  obtained  by  dilating  the  cervix  previous  to,  or  at  the 
time  of  operation,  and  passing  a  strip  of  gauze  down  through  it  into  the  vagina; 
hemorrhage  may  be  avoided  by  inducing  uterine  contractions  by  the  administra- 
tion of  ergot.  Some  of  these  objections  are,  therefore,  easily  set  aside,  and  it 
must  be  conceded  that  the  best  period  to  select  is  either  before  labor  has  begun  or 
shortly  thereafter,  before  there  is  any  exhaustion  of  the  mother. 

Technic. — The  general  principles  involved  in  all  abdominal  operations  apply 
to  Cesarean  section,  whether  the  vaginal  or  abdominal  route  is  selected.  Diihrssen 
has  taught  us  how  to  perform  the  operation  through  the  vagina;  Sanger,  through 
the  anterior  abdominal  wall.  It  should  always  be  performed,  if  possible,  in  a 
well-appointed  operating  room.  If  this  is  not  feasible,  and  it  is  necessary  to  use 
a  room  in  a  private  house,  every  attention  should  be  given  to  its  preparation  in 
order  to  secure  cleanliness  and  asepsis.  (See  chapter  on  Gynecological  Technic, 
Chap.  I,  Vol.  I.)  When  the  operation  is  performed  upon  a  woman  already  dead 
or  in  articulo  mortis,  it  may  be  done  upon  the  patient's  bed,  but  even  then,  if 
feasible,  it  is  better  to  transfer  her  to  a  suitable  table.  Patients  apparently  mori- 
bund may  survive  if  given  the  chance. 

The  preparation  of  the  patient  for  a  Cesarean  section  is  the  same  as  that  for 
all  abdominal  operations,  with  the  exception  that  a  well-trained  assistant  should 
be  at  hand  to  take  charge  of  the  infant  as  soon  as  it  is  delivered.  This  assistant 
must  be  responsible  for  the  new-born  child,  and  resuscitate  it  by  means  of  arti- 
ficial respiration,  etc.,  if  necessary. 


90  CESAKEAN   SECTION   AND    PORRO-CESAREAN    SECTION. 

The  instruments  required  are  as  follows : 

Scalpel. 

Strong  scissors,  straight  and  angular. 

One  dozen  or  more  hemostatic  forceps,  carefully  counted  and  recorded. 

One  pair  of  midwifery  forceps. 

Needle-holder. 

Needles. 

Silk  and  silkworm-gut  for  sutures. 

Hypodermic  syringe,  with  ergotin. 

Irrigator. 

Piece  of  elastic  cord  or  tubing,  three  feet  long  and  in  good  condition. 

Thermocautery. 

Catheter. 

Pair  of  retractors. 

Pedicle  needle. 

Curved  trocar. 

Vaginal  speculum  (Sims-Edebohls). 

Vaginal  retractors. 

Bladder  sound. 

Clover's  crutch  or  leg  supports. 
Incision. — Abdominal  Route. — The  abdominal  wall  is  cut  into;  the  skin  and 
fat  being  severed  with  one  sweep  of  the  knife.  The  sheath  of  the  rectus  muscle  is 
reached  and  opened  and  its  posterior  layer  cut  through,  or  the  incision  may  be 
carried  through  the  linea  alba.  The  preperitoneal  fat  bulges  into  the  wound  and 
can  be  raised  by  the  thumb  and  index-finger  of  the  left  hand.  It  is  then  held  up  by 
the  forceps  and  cut  into  with  the  scalpel.  The  peritoneum  will  now  be  seen,  and 
this  is  raised  and  cut  through,  care  being  taken  to  draw  it  well  away  from  the  abdom- 
inal cavity  so  that  the  underlying  intestines  are  not  injured.  The  part  of  the 
incision  by  which  the  abdomen  is  opened  should  be  higher  than  the  customary 
celiotomy  incision,  the  umbilicus  being  at  its  upper  third,  and  the  incision  about 
six  inches  long. 

After  the  abdominal  cavity  has  been  entered  it  is  easy  to  locate  the  bladder, 
and  the  incision  can  be  increased  downward  without  endangering  that  organ. 
Sufficient  room  must  be  obtained  for  the  delivery  of  the  child. 

Three  courses  are  now  open  to  the  operator.  It  has  been  recommended  that 
the  liquor  amnii  be  allowed  to  escape  through  the  cervix  in  order  that  the  size  of 
the  uterus  may  be  reduced.  The  loss  of  the  liquor  amnii  cannot,  in  any  way,  affect 
the  chances  of  the  fetus,  and  the  uterus  will  contract  just  as  well  as  if  the  amniotic 
fluids  were  extracted  through  the  new  opening  made  into  the  fundus.  In  this  way 
the  uterus  may  be  reduced  very  much  in  size,  and  can,  therefore,  be  removed  from 
the  abdominal  cavity  through  a  much  smaller  incision. 

Another  method  of  procedure  is  to  withdraw  the  uterus  from  the  abdominal 


INCISION    FOR    CESAREAN    SECTION. 


91 


cavity  without  puncturing  the  membranes  from  below  or  opening  into  them  or 
puncturing  them  from  above. 

The  third  method  of  procedure  is  to  open  the  uterine  cavity  while  still  in  situ 
within  the  abdomen.  If  it  has  been  decided  that  the  uterus  should  be  opened 
before  its  removal  from  the  abdominal  cavity,  precautions  must  be  taken  to  prevent 
the  escape  of  the  liquor  amnii  among  the  intestines.  Sponges  must  be  placed 
around  the  uterus  and  the  abdominal  walls  should  then  be  kept  in  as  close  apposi- 
tion to  the  anterior  surface  of  the  uterine  body  as  possible. 

The  first  method 
is,  perhaps,  the  ideal 
one.  The  organ  can 
be  better  controlled 
when  outside  the 
abdominal  cavity 
and  there  is  less 
danger  of  contam- 
ination of  the  peri- 
toneum by  the  es- 
cape of  intrauterine 
contents.  The  or- 
gan can  also  be 
more  readily  con- 
trolled with  the  fin- 
gers of  the  assistant 
placed  over  each 
uterine  artery.  Af- 
ter it  has  been  re- 
moved from  the  ab- 
dominal cavity  it  is 
well  to  place  two  or 
three  sutures  with 
which  to  approxi- 
mate the  upper  por-  Fig.  410. — Abdomen  Opened  and  Pregnant  Uterus  seen  Presenting. 

tion  of  the  opening 

through  the  abdominal  walls.  (vSee  Fig.  411.)  A  large,  flat  sponge  is  placed  to 
keep  back  the  intestines ;  sutures  are  kept  in  position  by  means  of  the  first  portion 
of  the  surgeon's  knot;  they  need  not  be  completely  tied,  as  they  are  only  tem- 
porary, and  can  be  readily  undone  after  the  uterus  is  ready  to  be  replaced  in  the 
abdomen. 

A  sterilized  towel  is  now  placed  beneath  the  uterus  and  another  covers  its  su- 
perior and  lateral  surfaces.  If  the  assistant  cannot  be  relied  upon,  the  operator 
may  feel  disposed  to  place  an  elastic  ligature  around  the  cervix,  and,  in  any  event, 
it  is,  perhaps,  best  to  do  so,  but  only  at  the  last  moment  before  incising  the  uteruSj 


92 


CESAREAN    SECTION   AND    PORRO-CESAREAN    SECTION. 


in  order  that  the  fetus  may  not  be  asphyxiated.  The  hgature  is  fastened  by  a  single 
tie,  and  the  two  ends  held  at  right  angles  to  the  knot  or  fastened  by  a  pair  of  com- 
pression forceps. 

Many  operators  have  remarked  the  difficulty  with  which  the  fetus  is,  at  times, 
resuscitated,  and  it  will  be  interesting  to  watch  the  favorable  influence  upon  the 
fetal  mortality  of  the  improved  methods  of  operating.  The  encircling  the  uterus 
with  an  elastic  ligature  probably  increases  infant  mortality. 

The  contraction  of  the  uterus  assists  in  preventing  hemorrhage.  The  handling 
of  the  uterus  and  its  exposure  to  the  air  will  excite  it  to  contract,  and  this  may  prove 
to  be  a  decided  advantage.     We  need  not  dread  any  increased  risk  from  removal 


Fig.  411. — Abdomen  Opened,  Uterus  Lifted  Out,  Temporary  Sutures  Placed. 
This  drawing  shows  the  ease  with  which  the  vessels  can  be  controlled. 


of  the  uterus  from  the  abdominal  cavity.  Those  wdio  have  pursued  this  practice 
are  satisfied  that  it  does  not  increase  the  shock. 

An  incision  is  now  made  into  the  uterine  wall  by  means  of  the  scalpel;  or  if 
the  operator  chooses  to  use  scissors,  he  may  do  so. 

If  the  amniotic  fluids  have  escaped  from  below,  the  membranes  will  not  bulge 
into  the  incision  unless  the  placenta  is  in  the  way.  The  membranes  may  be  tapped 
with  an  ovariotomy  trocar  and  the  amniotic  fluids  can  in  this  way  be  conveyed  to  a 
vessel  held  by  one  of  the  assistants.  The  danger  of  escape  of  fluid  into  the  abdom- 
inal cavity  is  thus  largely  minimized. 

If  the  placenta  is  on  the  anterior  wall,  an  incision  into  the  uterus  brings  the  opera- 


TECHNIC    OF    CESAREAN   SECTION.  93 

tor  face  to  face  with  all  the  features  of  placenta  prsevia.  No  attempt  should  be  made 
to  strip  off  the  placenta  from  the  sinuses,  but  it  should  be  rapidly  torn  through  and  the 
fetus  reached.  The  fetal  parts  should  be  seized  and  a  quick  delivery  effected. 
When  making  an  incision  into  the  uterus,  it  should  be  made  long  enough  to  permit 
of  the  ready  extraction  of  the  fetus  without  tearing  the  uterine  wall.  When  the 
body  of  the  child  is  drawn  into  the  wound  the  pressure  assists  in  preventing  any 
further  loss  of  blood.  It  is  here  that  presence  of  mind  and  an  exact  knowledge  of 
what  should  be  done  are  of  great  service  to  the  patient.  A  rapid  operation  means 
a  minimum  loss  of  blood.  All  surgeons  who  have  performed  this  operation  have 
been  struck  with  this  fact.  It  is  a  good  thing  to  know  exactly  what  to  do  and  how 
to  do  it.  Armed  with  this  knowledge,  we  need  have  no  fear  in  dealing  with  the 
placenta. 

The  hand  of  the  operator  is  passed  rapidly  into  the  uterine  cavity,  one  foot  or 
the  two  feet  are  grasped,  and  the  buttocks  and  body  of  the  child  are  rapidly  delivered, 
and  perhaps  the  head  may  come  away  without  difficulty.  If  an  arm  is  grasped 
it  should  be  dropped  and  a  foot  sought  for.  If  delivery  is  accomplished  by  draw- 
ing on  an  arm,  the  uterine  opening  must  be  larger  than  for  a  delivery  by  one  or 
both  feet. 

It  occasionally  happens  that  the  head  has  become  impacted  at  the  pelvic  brim. 
As  a  rule,  a  little  traction  will  dislodge  it,  but  if  not,  the  hand  of  the  third  assistant 
can  be  passed  into  the  vagina  and  the  head  pushed  up  so  that  it  may  be  easily  de- 
livered from  above.  The  uterine  muscular  fiber  at  the  incision  may  contract  about 
the  child's  neck;  this  difficulty  can  be  easily  overcome  by  nimble  fingers,  provided 
the  uterine  incision  is  large  enough  to  permit  extraction.  A  pair  of  midwifery 
forceps  should  always  be  at  hand,  but  will  scarcely  ever  be  needed.  The  delivery 
of  the  child  should  be  rapid  in  order  that  its  life  may  be  saved.  Clamps  should 
be  applied  to  the  cord  in  two  places  and  the  cord  cut  through  between  them.  The 
fetus  is  then  handed  to  the  assistant,  and  he  must  be  expert  enough  to  perform 
artificial  respiration  if  it  is  recjuired. 

The  placenta  has  now  to  be  dealt  with.  The  operator  should  instruct  his  assis- 
tant either  to  tighten  the  elastic  ligature  or  to  put  compression  on  the  uterine  arteries 
with  his  fingers.  The  life  of  the  fetus  is  not  endangered  by  this  procedure,  as  it 
has  been  delivered.  If  the  elastic  compression  is  applied  too  early,  it  is  likely  to 
paralyze  the  uterus  and  prevent  proper  uterine  contraction.  If  the  uterus  contracts 
well  there  need  be  no  hesitation  about  removing  the  placenta;  the  more  it  bleeds, 
the  more  rapidly  should  its  removal  be  accomplished.  The  hand  should  be  passed 
in  and  the  placenta  loosened  by  a  sweep  and  immediately  removed.  After  its 
removal  we  have  a  much  better  opportunity  of  controlling  hemorrhage  than  while 
it  is  partly  in  situ.  It  may  not  be  necessary  to  grasp  any  of  the  vessels  nor  yet  to 
grasp  the  fundus,  provided  contraction  takes  place  and  the  delivery  is  rapidly 
accomplished. 

There  will  now  be  some  oozing  from  the  uterine  incision.  This  can  be  controlled 
by  the  approximation  sutures.     For  this  purpose  silk  is  usually  used  in  preference 


94  CESAREAN   SECTION   AND    PORRO-CESAREAN   SECTION. 

to  catgut.  The  needles  employed  should  not  have  too  great  a  cutting  surface  and 
they  should  not  be  larger  than  is  necessary  to  convey  a  sufficiently  strong  thread. 
The  deep  sutures  should  be  placed  at  intervals  of  about  a  quarter  of  an  inch;  they 
should  not  be  placed  close  enough  together  to  produce  complete  anemia  of  the 
wound.  The  ends  of  thread  should  be  cut  close  to  the  knot.  Care  must  be  taken 
that  the  sutures  do  not  perforate  the  mucous  membrane  of  the  uterus.  They  must 
be  tied  firmly  in  order  that  the  approximation  may  be  complete,  but  not  firmly 
enough  to  produce  a  dangerous  amount  of  constriction.  If  the  tissues  are  too  greatly 
constricted  they  lose  their  vitality.  After  the  sutures  have  been  brought  together, 
oozing  from  the  surface  of  the  wound  may  still  be  noticed. 

It  is  now  wise  to  apply  the  mattress  suture,  approximate  carefully  the  serous 
covering  of  the  uterus,  bury  the  deep  sutures,  add  additional  protection  against 
sepsis,  and  prevent  further  oozing  of  blood.  A  needle  is  passed  through  the  peri- 
toneum at  a  little  distance  from  the  edge  of  the  wound  and  carried  across  the  wound. 
It  is  then  passed  through  the  serous  coat  on  the  opposite  side  of  the  wound  and  car- 
ried parallel  to  the  cut;  then  brought  back  over  the  incision  and  at  right  angles  to 
it,  to  pierce  the  peritoneal  coat  in  the  same  manner  as  in  the  first  part  of  the 
stitch.  In  this  way  a  rectangular  stitch  is  placed  with  one  side  of  the  rectangle 
wanting;  this  side  is  completed  by  tying  the  two  free  ends  of  the  suture.  This 
stitch  when  used  upon  the  intestines  is  water-tight.  By  means  of  it  the  serous  coat 
on  one  side  of  the  incision  is  brought  into  accurate  contact  with  that  on  the  other 
side. 

The  surface  is  now  washed  of!  with  sterilized  water  or  normal  salt  solution, 
the  towels  are  removed  from  about  the  uterus,  the  temporary  sutures  placed  in  the 
abdominal  wall  are  loosened  and  the  ends  grasped  by  forceps  on  either  side  to  pre- 
vent their  accidental  removal.  Gauze  sponges  placed  in  the  abdominal  cavity 
are  removed,  the  cul-de-sac  of  Douglas  is  cleansed,  and  the  uterus  is  dropped  back 
into  the  abdominal  ca\dty.  The  vesical  pouch  is  cleansed  and  the  abdominal 
sutures  are  then  placed  in  position.  Those  who  prefer  the  tier  suture  will  suture 
in  tiers;   those  who  prefer  the  en  masse  suture  will  suture  en  masse. 

Once  more  the  incision  in  the  uterus  is  inspected  to  see  that  the  hemorrhage 
has  ceased.  The  omentum  may  be  pulled  down,  but  it  does  not  remain  long  in 
front  of  the  uterus.  It  soon  draws  up  above  the  fundus.  It  has  been  recommended 
that  the  omentum  should  be  pushed  into  the  cul-de-sac  of  Douglas  to  permit  of 
adhesions  between  the  uterus  and  the  anterior  abdominal  wall.  It  is  unnecessary 
to  do  this,  as  the  uterus  is  soon  free  of  omentum  as  above  described. 

The  usual  dressing  is  now  applied  to  the  wound,  and  this,  in  turn,  is  covered  by 
a  pad  of  steriUzed  absorbent  cotton.  The  dressing  is  then  kept  in  place  by  means 
of  adhesive  strapping  and  a  binder. 

"  The  patient  should  now  be  placed  in  a  bed  warmed  for  her  reception.  She 
should  be  stimulated  by  the  application  of  heat.  Pain  may  be  allayed  by  the  sub- 
cutaneous injection  of  I  grain  of  morphin.  Vomiting,  as  a  rule,  is  not  excessive. 
The  administration  of  chloroform  to  a  pregnant  woman  does  not  seem  to  be  fol- 


AFTER-TREATMENT   OF    CESAREAN   SECTION.  95 

lowed  by  much  vomiting.  There  must  be  some  chemical  antidote  in  the  blood  of  a 
pregnant  woman  which  prevents  chloroform  from  producing  vomiting.  If  great 
thirst  is  complained  of,  it  may  be  relieved  by  means  of  rectal  enemata,  or  the  patient 
may  be  allowed  to  suck  ice  placed  in  gauze  and  dropped  in  the  mouth,  the  fluid 
from  which  is  allowed  to  run  into  a  vessel  placed  under  the  patient's  cheek.  This 
will  be  found  very  refreshing.  After  a  time,  fluid  is  allowed  in  small  quantities. 
The  diet  at  first  consists  of  milk,  beef-tea,  and  other  fluids. 

It  may  be  necessary  to  use  the  catheter  every  six  hours,  but,  if  the  patient  can 
pass  urine  voluntarily,  she  should  be  permitted  to  do  so.  If  flatus  collects  and  gives 
rise  to  colicky  intesdnal  pains,  it  may  be  relieved  by  the  administration  of  an  enema, 
consisting  of  turpentine  and  soapsuds,  one  dram  to  the  pint.  The  bowels  should 
be  moved  by  the  administration  of  calomel  followed  by  a  saline,  administered  before 
any  marked  distention  occurs.  Purgatives  may  be  given  as  soon  as  the  stomach 
will  retain  them.  It  is  quite  unnecessary  to  wait  for  four  or  five  days  to  secure 
thorough  evacuation  of  the  bowels.  The  sooner  they  are  evacuated,  the  better 
the  patient  will  convalesce. 

The  child  may  be  put  to  the  breast  within  twenty-four  hours  after  the  operation. 
In  some  cases  the  secretion  of  milk  will  suddenly  disappear,  but  will  reappear  two 
or  three  days  later. 

If  gauze  has  been  placed  down  through  the  cervix,  it  should  be  removed  in  from 
twenty-four  to  thirty-six  hours.  It  will  be  quite  unnecessary  to  repack  the  uterine 
ca\'ity. 

Vaginal  injections  must  be  carefully  given  if  given  at  all.  Bichlorid  of  mercury 
solution,  1  :  2000  or  3000,  will  answ^er  very  well  if  followed  by  plain  water  to  pre- 
vent any  irritation  of  the  vaginal  mucous  membrane.  If  the  patient  has  no  fever, 
and  the  lochia  has  no  offensive  odor,  douches  are  contraindicated. 

The  patient  should  wear  an  abdominal  binder  for  some  months  after  recovery. 

There  is  sometimes  a  sharp  rise  of  temperature  during  the  convalescence. 
The  rise  of  temperature  and  elevation  of  pulse  may  occur  within  twenty-four  to 
thirty-six  hours  from  the  time  of  the  operation.  After  thorough  evacuation  of  the 
bowels  has  been  obtained  the  temperature  drops,  the  pulse  becomes  less  rapid, 
and  convalescence  proceeds  without  further  incident.  Occasionally  sharp  pains 
may  be  felt  over  the  front  of  the  uterus  in  the  neighborhood  of  the  incision. 

There  are  other  features  to  be  considered  in  connection  with  this  operation.  The 
incision  itself  has  been  varied;  some  contending  it  should  be  made  in  front  of  the 
uterus,  others  behind,  and  Fritsch  employed  the  transverse  incision  in  the  fundus 
between  the  cornua.  In  one  instance  this  was  not  sufficient  to  permit  of  the  re- 
moval of  the  fetus  until  after  a  vertical  incision  had  been  made  at  right  angles  to 
the  first. 

Cohnstein^  recommended  that  the  uterus  should  be  turned  out  of  the  abdominal 
ca\dty  and  that  the  opening  should  then  be  made  on  the  posterior  surface.  After 
the  organ  has  been  replaced  in  the  abdomen,  drainage  is  secured  by  an  incision 
1  Cohnstein:  "Zur  Sectio  csesarea,"  Centralblatt  f.  Gynak.,  1881,  Bd.  v,  Xr.  12,  S.  289. 


96  CESAREAN    SECTION   AND    PORRO-CESAREAN   SECTION. 

through  the  cul-de-sac  of  Douglas  and  the  introduction  of  gauze  from  the  vagina 
through  the  opening.  He  claims  that  the  patient  is  thus  protected  should  any  leak- 
age occur  from  the  uterine  incision,  and,  also,  that  the  anterior  abdominal  wall  can 
be  completely  closed  while  this  object  is  secured.  The  intestines,  under  these 
circumstances,  are  more  out  of  the  way  and  the  general  cavity  of  the  peritoneum 
is  not  as  liable  to  be  invaded  by  a  progressive  septic  peritonitis  as  when  the  anterior 
incision  is  used. 

The  author  cannot  agree  with  this  opinion,  but  favors  the  anterior  incision 
into  the  uterine  wall,  an  incision  that  should  be  vertical,  in  the  median  line,  reaching 
from  the  upper  surface  of  the  bladder  below,  upward  as  far  as  may  be  necessary  to 
permit  of  easy  delivery  of  the  child. 

If  gauze  drainage  is  placed  in  the  uterine  cavity,  great  care  must  be  taken  to 
see  that  it  can  be  removed  without  difficulty.  It  is  not  wise  to  risk  much  distur- 
bance of  the  uterus  after  operation.  The  gauze  must  be  so  coiled  that  it  will  run 
easily  through  the  cervix  when  pulled  upon.  It  is  not  necessary  to  use  gauze  in 
the  interior  of  the  uterus  when  a  careful  suturing  of  the  uterine  wall  has  been  car- 
ried out.  The  mattress  sutures  already  spoken  of  should  never  be  omitted.  When 
they  have  been  properly  applied  neither  gauze  drainage  of  the  uterus,  nor  drainage 
of  any  kind  of  the  abdominal  cavity,  will  be  indicated,  with  the  single  exception 
mentioned  below. 

If  at  the  time  of  the  operation  the  uterus  is  septic,  the  fetus  dead,  and  the  uterine 
mucous  membrane  a  greenish  tinge,  and  it  is  decided  not  to  amputate  the  organ, 
the  cavity  of  the  uterus  should  be  packed  with  iodoform  gauze,  a  portion  of  which 
is  allowed  to  pass  downward  through  the  cervix.  The  uterine  wound  should  be 
thoroughly  disinfected  before  it  is  finally  closed  by  the  tightening  of  the  sutures. 
When  the  serous  membrane  is  brought  carefully  together  over  the  surface,  we  place 
a  barrier  on  the  peritoneal  side  so  that  any  pus  that  may  form  will  be  discharged 
into  the  uterine  cavity.  It  is  quite  unnecessary,  as  a  matter  of  routine,  to  wash 
the  uterine  cavity.  If  it  is  irrigated,  care  must  be  taken  not  to  allow  the  water  to 
enter  the  abdominal  cavity.  When  the  uterine  cavity  is  thoroughly  dried  out  and 
packed  with  iodoform  gauze,  no  irrigation  is  required. 

If  the  operator  has  a  doubt  as  to  the  condition  of  the  uterus  he  may  insure  the 
greater  safety  of  his  patient  by  packing  iodoform  gauze  over  the  anterior  surface 
of  the  uterus,  to  shut  off  the  rest  of  the  peritoneal  cavity  from  this  region.  If  any 
contamination  takes  place  through  the  wound  in  the  uterine  wall,  the  gauze  pro- 
tects the  patient  from  a  general  peritonitis.  Gauze  packing  in  front  and  gauze 
drainage  within  the  uterine  and  vaginal  cavities  may  prove  of  great  service  in  some 
of  these  cases.  The  objection  to  the  packing  in  front  is  that  it  is  liable  to  permit 
hernia  to  occur  at  a  later  date. 

In  dealing  with  the  uterine  wound  we  have  to  contend  with  the  healing  process 
in  an  organ  that  is  undergoing  involution  as  well  as  alternate  contractions  and 
relaxations.  The  contractions  of  the  organ  are  a  benefit  in  preventing  leakage 
into  the  abdominal  cavity,  provided  we  have  free  drainage  through  the  cervix. 


STATISTICS    OF   CESAREAN   SECTION.  97 

It  was  found  that,  in  spite  of  all  precautions,  the  wound  in  the  uterus  had  a 
tendency  to  gape.  On  this  account  Kehrer  made  a  transverse  incision  at  the  level 
of  the  OS  internum,  claiming  that  such  a  wound  had  less  disposition  to  remain  open. 
Sanger,  however,  taught  us  to  approximate  carefully  the  edges  of  the  wound  by 
means  of  sutures,  and  to  reinforce  this  by  obtaining  union  between  two  flaps  of 
peritoneum.  It  was  claimed  that  the  serous  coats  united  more  quickly  than  the 
muscular  coats  and  formed  a  better  barrier  against  the  escape  of  the  intrauterine 
contents.  The  muscular  tissue  was  resected,  and  a  portion  of  the  peritoneum 
was  thus  freed  from  the  muscle  beneath.  We  have  learned,  however,  that 
this  resection  of  muscular  tissue  is  quite  unnecessary.  The  peritoneum  is  lax 
enough  without  this,  and  if  not  it  can  be  easily  loosened  by  passing  a  scalpel 
beneath  it. 

When  we  see  the  difficulty  encountered  in  getting  accurate  union  of  the  uterine 
wound,  we  must  conclude  that  the  wound  should  never  be  torn,  as  has  been  recom- 
mended.    It  was  supposed  that  this  tearing  of  the  wound  prevented  hemorrhage. 

The  frequency  with  which  gangrene  of  the  uterine  wound  is  mentioned  in  post- 
mortem records  bespeaks  the  prevalence  and  activity  of  septic  germs. 

The  danger  of  a  long  incision  is  the  subsequent  occurrence  of  hernia,  and  another 
operation  may  be  required  to  relieve  this.  It  is  a  question  whether  this  contention 
is  correct  or  not.  All  abdominal  operators  know  that  hernia  does  occur  from  small 
incisions,  and  that  large  incisions  will  heal  quite  firmly  and  strongly  when  properly 
approximated. 

It  is  my  own  opinion  that  in  every  case  in  which  future  pregnancies  may  take 
place,  and  the  patient  expresses  a  wish  to  avoid  the  same,  they  should  be  prevented 
by  an  excision,  with  scissors,  between  two  ligatures,  of  a  small  portion  of  each 
Fallopian  tube. 

Statistics. — After  such  a  series  of  cases  as  that  given  by  Reynolds,  of  Boston, 
it  is  scarcely  necessary  to  quote  statistics  at  length.  They  can  be  made  to  prove 
almost  anything.  There  was  a  time  when  nearly  all  the  cases  of  Cesarean  section 
terminated  fatally.  Each  collector  of  statistics  has  had  his  own  mortality  percen- 
tage. For  instance,  Michaelis  stated  that  54  per  cent,  recovered;  Kaiser,  that  38 
per  cent,  recovered;  Mayer,  54  per  cent.;  Pihan-du  Fillhay,  57  per  cent.;  and 
Harris,  40  per  cent.  These  statistics  are  given  by  Lusk.  It  is  unnecessary  to 
pursue  statistics  further.  What  has  been  true  in  the  past  cannot  influence  either 
what  is  true  now  or  in  the  future. 

The  statement  is  well  founded  that  cases  in  private  practice  present  a  lower 
death-rate  than  those  in  hospitals.  In  private  practice  the  cases  that  are  operated 
upon  are  generally  in  a  better  state  of  health,  and  there  may  be  a  slighter  degree 
of  deformity.  In  private  practice  the  chances  are  that  the  operation  will  be  per- 
formed earlier  and  under  more  favorable  conditions,  or  that  the  patient  will  be 
sent  to  the  hospital  when  local  conditions  are  not  favorable  for  operation. 

The  mortality  in  those  cases  in  which  operations  have  been  repeated  upon  the 
same  patient  has  been  lower  than  in  cases  in  which  a  single  operation  has  taken 


98  CESAREAN    SECTION   AND    PORRO-CESAREAN    SECTION. 

place.  The  reason  for  this  will  probably  be  found  in  the  fact  that  the  second  opera- 
tion has  been  elective  and  has  been  performed  at  a  favorable  time  with  favorable 
surroundings. 

The  statistics  compiled  by  Harris  show  that  the  mortality  rate  is  higher  in  the 
cities  than  in  the  towns,  and  higher  in  the  towns  than  in  the  country.  These  sta- 
tistics antedate  the  present  era. 

A  large  majority  of  the  patients  die  during  the  first  three  days.  Two  cases  have 
been  reported  in  which  each  patient  had  been  operated  upon  four  times. 

In  his  statistics  of  Cesarean  section,  Harris  states  that  in  nine  cases  in  which 
the  uterus  was  not  sutured,  none  recovered.  He  mentions  two  cases  in  which  cat- 
gut was  used,  and  both  died.  As  a  consequence  of  his  investigations  he  is  much 
in  favor  of  Porro's  operation. 


DUHRSSEN'S  VAGINAL  CESAREAN  SECTION. 
The  operation  as  carried  out  by  Diihrssen  is  as  follows:  The  vagina  is  washed 
and  sterilized,  the  bladder  emptied,  and  the  parts  about  the  vaginal  vault  exposed 
by  means  of  retractors.  The  cervix  having  been  pulled  down,  an  incision  is  made 
through  the  mucous  membrane  of  the  vagina,  and  the  bladder  pushed  up  out  of 
the  way,  as  in  the  first  stage  of  vaginal  hysterectomy.  Appreciating  that  the  blood- 
supply  reaches  the  uterus  through  the  uterine  arteries  on  each  side,  and  that  the 
place  in  which  the  fewest  important  vessels  will  be  cut  is  in  the  median  line  in  front, 
Diihrssen,  after  getting  the  bladder  well  out  of  the  way,  incised  with  strong  scissors 
the  anterior  wall  of  the  cervix  and  the  anterior  wall  of  the  uterus  until  a  sufficient 
opening  was  made  to  permit  of  ready  delivery  of  the  fetus.  He  states  that  he  has 
performed  the  operation  in  eight  minutes.  It  is  only  of  service  in  cases  in  which  it 
is  desirable  to  empty  the  uterus  rapidly,  and  is  not  suitable  for  cases  in  which 
there  is  any  obstruction  to  delivery  in  the  pelvis.  The  chief  indication  for  its 
employment  is  puerperal  eclampsia.  The  uterine  wall  may  be  stitched  up  with 
catgut,  a  gauze  drain  placed,  and  a  vaginal  tamponade  made  with  iodoform  gauze. 
The  hemorrhage  from  the  wound  in  the  uterus  is  but  slight  so  long  as  it  is  made  in 
the  median  line  in  front. 


PORRO-CESAREAN  SECTION. 

History. — This  operation  was  first  recommended  by  Blundell,  of  London. 
Porro's  first  successful  case  was  performed  in  May,  1876,  although  Harris  thinks 
the  operation  was  done  in  Boston  in  July,  1868.  Spaeth,  of  Vienna,  performed  the 
operation  a  short  time  after  Porro's  first  case,  and  successfully.  The  patient  was  a 
dwarf  primipara  who  had  been  in  labor  for  several  hours.  The  child  was  removed 
by  Cesarean  section,  but  the  uterus  did  not  contract  sufficiently  to  stop  the  hemor- 
rhage and  the  operator  decided  to  remove  the  organ. 

Before  the  operation  was  carried  out  on  woman,  experiments  were  made  by  the 


PORRO-CESAREAN    SECTION.  99 

removal  of  the  uterus  from  bitches.  They  survived  the  operation,  and  the  conclu- 
sion was  arrived  at  that  the  uterus  could  be  safely  removed  after  the  delivery  of 
the  fetus  by  Cesarean  section.  Blundell  thought  that  the  removal  of  the  uterus 
would  increase  the  safety  of  a  Cesarean  section  by  removing  the  organ  that  was 
likely  to  become  septic,  or  likely  to  leak  into  the  abdominal  cavity.  Harris,  who 
has  made  a  careful  study  of  these  operations,  is  a  very  warm  advocate  of  Porro's 
operation. 

Conditions  for  Which  the  Operation  may  be  Performed. — Porro-Cesarean 
operations  may  be  divided  into  three  groups : 

First,  Cesarean  section  followed  by  amputation  of  the  uterus,  or  the  true  Porro 
operation. 

Secondly,  amputation  of  a  pregnant  uterus  before  the  fetus  is  viable. 

Thirdly,  the  removal  of  an  extrauterine  fetus  from  the  abdominal  cavity,  followed 
by  amputation  of  the  uterus. 

This  last  operation  may  be  performed  for  rupture  of  the  uterus  or  vagina  with 
intra-abdominal  delivery  of  the  fetus;  or,  it  may  be  advisable  to  remove  the  uterus 
to  control  the  hemorrhage  when  operating  in  these  cases  of  extrauterine  pregnancy 
in  the  later  months. 

The  indications  for  the  performance  of  the  Porro  operation  must  necessarily 
include  the  two  indications  thought  of  by  Blundell,  namely,  the  removal  of  the 
septic  uterus  and  the  control  of  an  otherwise  uncontrollable  hemorrhage.  The 
writer  would  add  to  these  another  indication  that  has  lately  come  under  his  notice, 
namely,  the  removal  of  the  pregnant  uterus  on  account  of  gangrene  of  a  fibroid 
tumor.  He  had  one  such  case  in  the  summer  of  1906.  The  patient,  a  negress, 
had  been  troubled  with  a  fibroid  tumor  for  some  years.  She  became  pregnant. 
Symptoms  of  profound  sepsis  suddenly  set  in ;  the  tumor  became  excessively  tender 
and  the  patient  extremely  ill.  An  exploratory  incision  was  made,  and  the  largest 
nodule  of  a  multinodular  myoma,  about  the  size  of  a  child's  head,  was  found  gan- 
grenous. Porro's  operation  was  performed  and  she  made  an  excellent  recovery. 
(Reported  by  Dr.  Thistle,  of  Toronto.) 

There  is  one  absolute  indication  for  the  operation,  that  is,  the  control  of  an 
otherwise  uncontrollable  hemorrhage.  It  must  then  be  done  to  save  life.  It  does 
not  matter  what  the  cause  of  the  hemorrhage  is. 

There  are  other  indications  that  are  not  absolute,  and  these  require  careful 
consideration : 

First,  the  removal  of  an  infected  uterus. 

Secondly,  the  removal  of  the  uterus  owing  to  the  fact  that  there  is  partial  or 
total  obstruction  of  the  parturient  canal  by  tumors  or  excessively  rapid  growth  of  a 
myoma  during  pregnancy  (Fig.  412). 

Thirdly,  the  removal  of  the  uterus  on  account  of  osteomalacia. 

Fourthly,  the  removal  of  the  uterus  on  account  of  cancerous  disease  of  the  cervix. 

A  uterus  may  appear  to  be  infected;  it  may  have  a  greenish  appearance  of  its 
interior,  yet  the  case  may  progress  satisfactorily  if  the  operation  is  performed  in 


100 


CESAREAN    SECTION   AND    PORRO-CESAREAN    SECTION. 


the  ordinary  way  and  the  uterus  is  left  in  situ.  This  greenish  appearance  of  the 
interior  is  not  always  an  indication  of  a  virulent  infection.  Moreover,  the  removal 
of  an  infected  uterus  may  not  save  the  patient,  nor  its  non-removal  cause  her  death. 
Many  women  are  infected  subsequent  to  labor  and  recover  in  a  short  time  without 
the  removal  of  the  uterus. 

If  drainage  through  the  cul-de-sac  of  Douglas  is  instituted  and  the  incision  made 


Fig.  412. — Pokbo-Cesarean  Section  Owing  to  Rapid  Growth  of  Edematous  Myoma  During  Pregnancy 

(J.  F.  W.  Ross). 


in  the  posterior  wall  of  the  uterus,  as  has  been  suggested  by  Cohnstein,  the  removal 
of  the  uterus  is  scarcely  required ;  or,  if  the  gauze  packing  is  placed  over  the  uterine 
sutures  in  front,  as  suggested  in  discussing  the  operation  of  Cesarean  section,  it  is 
unnecessary  to  remove  the  infected  uterus.  The  removal  of  the  uterus  under  such 
circumstances  is  certainly  not  a  conservative  measure. 

When  one  has  seen  recovery  after  rupture  of  the  uterus  from  prolonged  labor  or 
miscarriage,  where  gauze  has  been  placed  down  through  the  opening  into  the  uterine 


PORRO-CESAREAN    SECTION. 


101 


cavity  and  on  into  the  vagina,  where  no  sutures  have  been  placed,  he  must  conclude 
that  recovery  is  quite  possible  after  the  uterus  has  been  incised  and  the  fetus  removed, 
even  if  the  uterus  is  an  infected  organ.     (See  Fig.  413.) 

The  removal  of  the  uterus,  because  there  is  partial  or  total  obstruction  of  the 
parturient  canal  from  a  tumor,  is  scarcely  a  justifiable  procedure.  The  removal 
of  a  portion  of  each  Fallopian  tube  is  sufficient  to  prevent  subsequent  pregnancies, 
and  the  patient  is  thus  permitted  to  retain  her  ovaries  and  tubes  and  all  the  functions 
that  pertain  thereto,  with  the  exception  of  pregnancy.  A  contrary  opinion  is  held 
by  others  with  refer- 
ence to  the  advisability 
of  hysterectomy  for  the 
pregnant  uterus  con- 
taining fibroids. 

In  cases  of  osteo- 
malacia the  same  ar- 
gument holds  good  as 
in  cases  in  which  the 
pelvis  is  obstructed  by 
tumors. 

It  is  useless  to  am- 
putate the  uterus  in 
case  of  cancerous  dis- 
ease. Under  such  cir- 
cumstances, pan-hys- 
terectomy, or  total  re- 
moval of  the  uterus, 
and  not  Porro's  oper- 
ation, should  be  car- 
ried out.  If  this  can- 
not be  done,  Cesarean 
section     will     answer 

every  purpose.  To  add  the  shock  of  an  amputation  of  the  uterus  to  a  patient 
who  has  been  bleeding  for  weeks  from  the  cancerous  cervix  of  a  pregnant  uterus 
can  scarcely  be  a  wise  procedure.  Such  cases  have  succumbed  on  the  table.  The 
only  indication  for  the  removal  of  a  uterus  in  which  cancerous  disease  exists  is  the 
usual  one  for  Porro's  operation — uncontrollable  hemorrhage.  But  even  though 
the  hemorrhage  ceases  from  the  fundus  after  the  amputation,  it  is  likely  to  continue 
from  the  cervix. 

If  ergot  is  used  judiciously  before  the  performance  of  the  operation,  inertia  of 
the  uterus  will  not  be  so  frequently  met  with,  and  Porro's  operation  will  not  be  so 
frequently  indicated. 

The  fact  that  so  many  women  have  been  obliged  to  have  the  fetus  removed  by 
Cesarean  section,  in  successive  pregnancies,  is  no  argument  for  the  performance 


Fig.  413. — Uterus  Ruptured  by  Hand  of  a  Young  Surgeon. 
Abdominal  operation;  gauze  drainage  of  wound  in  uterus.     Recovery  with- 
out removal  of  uterus  (operated  on   by  J.  F.  W.  Ross  ten  hours  after  uterus 
had  been  ruptured). 


102  CESAREAN   SECTION   AND    POREO-CESAEEAN   SECTION. 

of  Porro's  operation.  It  has  already  been  shown  how  this  difficuUy  may  be  over- 
come by  a  simple  procedure  to  prevent  subsequent  impregnation,  namely,  resection 
of  the  Fallopian  tubes. 

Operation. — The  preliminaries  of  this  operation  are  similar  to  those  described 
under  the  head  of  Cesarean  section.  The  instruments  to  be  used  are  the  same, 
except  that  the  operator  must  provide  himself  with  a  small  Koberle  serre-noeud 
and  some  piano-wire  if  he  desires  to  treat  the  stump  by  the  so-called  "extraperi- 
toneal" method.  The  uterus  is  drawn  out  of  the  abdominal  cavity,  or  it  may  be 
left  in  the  abdominal  cavity  until  after  it  has  been  emptied,  or  the  membranes  may 
be  punctured  from  below,  the  amniotic  fluid  aUowed  to  escape,  and  the  uterus  then 
drawn  through  the  abdominal  incision. 

If  the  fetus  is  not  viable,  it  is  unnecessary  to  open  the  uterine  cavity.  A  preg- 
nant uterus  may  be  the  seat  of  one  or  more  fibroid  tumors  that  have  been  growing 
with  great  rapidity  during  the  period  of  pregnancy. 

When  we  are  satisfied  that  it  is  advisable  to  remove  the  uterus,  the  wire  of  the 
serre-noeud  may  be  placed  around  the  cervix.  In  those  cases  in  which  the  uterine 
cavity  is  not  opened  into,  the  ovarian  and  uterine  arteries  will  be  ligated  before  the 
wire  is  passed  around  the  cervix.  After  the  ovarian  artery  has  been  encircled  by  a 
ligature,  the  ligature  is  tied,  a  pair  of  clamp  forceps  is  placed  on  the  uterine  end, 
the  tissues  are  cut  through  by  means  of  a  pair  of  scissors,  the  peritoneum  is  pushed 
downward  with  the  handle  of  a  scalpel,  and  the  uterine  artery  is  felt  for  with  the 
finger  and  thumb  of  the  left  hand.  When  found,  it  is  held  and  a  ligature  passed 
between  it  and  the  cervix,  close  to  the  cervical  tissue,  by  means  of  a  blunt  pedicle 
needle.  This  ligature  is  now  tightly  tied  and  the  broad  ligament  is  cut  downward, 
close  to  the  cer\dx.  The  ovarian  and  uterine  arteries  are  similarly  tied  on  the  oppo- 
site side,  care  being  taken  to  avoid  the  ureters.  The  bladder  must  not  be  pinched 
in  the  wire  of  the  serre-noeud  (if  it  is  used).  To  avoid  injury  to  the  ureters,  it  is 
necessarv  that  the  ligature  around  the  uterine  arteries  should  be  placed  close  to 
the  cervix  after  the  bladder  has  been  mapped  out.  To  avoid  the  bladder,  it  is 
wise  to  incise  the  peritoneum  over  the  front  of  the  cervix  and  to  push  it  downward. 
Before  the  first  puncture  of  the  pedicle  needle  is  made  to  secure  the  uterine  artery,  it 
is  advisable  to  place  a  sound  in  the  bladder  to  ascertain  its  exact  limitations,  and 
wise  to  place  artery  forceps  above  in  the  median  line  and  at  each  upper  angle  so  as 
to  define  these  limitations.  A  simple  method  of  determining  the  limitations  of 
the  bladder  is  compression  of  the  organ  by  one  or  two  small  sponges,  forcing  the 
urine  to  its  upper  boundaries.  They  can  in  this  way  be  easily  mapped  out  and 
marked  by  forceps  placed  upon  them  as  already  mentioned.  If  the  clamp  is  used 
it  is  tightened  and  the  uterus  amputated. 

The  writer  considers  the  use  of  the  clamp  entirely  unnecessary.  The  old  method 
of  treating  the  stump  extraperitoneally  by  means  of  Koberle's  serre-noeud  is  rarely 
practised  by  modern  operators.  In  former  days  the  stump  was  placed  in  the 
lower  angle  of  the  wound  and  supported  by  transfixing  it  with  pedicle  pins.  These 
pins  prevented  the  serre-noeud  from  slipping  away  from  its  position.  Before  the 
pedicle  was  placed  in  the  wound,  the  vesico-uterine  pouch  was  cleansed,  the  cul- 


PORRO-CESAREAN   SECTION.  103 

de-sac  of  Douglas  wiped,  and  some  operators  inserted  a  drainage-tube.  The 
wound  was  then  closed  upon  the  stump.  When  the  stitches  were  placed  the  parie- 
tal peritoneum  adhered  to  the  peritoneum  of  the  stump  beneath  the  wire  of  the 
serre-noeud  and  prevented  discharge  from  leaking  into  the  abdominal  cavity.  The 
wound  was  dressed  with  absorbent  pads  after  it  had  been  dusted  with  iodoform, 
aristol,  or  some  other  powder. 

It  was  desirable  that  the  tissue  beyond  the  wire  be  mummified,  and  for  this 
purpose  perchlorid  of  iron  solution  was  used.  This  was  rubbed  into  the  raw  sur- 
face of  the  stump,  taking  care  to  prevent  the  iron  solution  from  entering  the  abdominal 
cavity  and  to  keep  out  any  discharge  of  blood  that  might  occur.  The  wire  was  tight- 
ened if  hemorrhage  occurred;  and  if  no  hemorrhage  occurred,  it  was  tightened  every 
day.  At  the  end  of  a  fortnight  the  clamp  came  away,  together  with  the  strangu- 
lated tissues  on  its  distal  side.  If  it  loosened,  it  was  not  wise  to  remove  it  by  cutting 
across  the  remaining  tissues  with  scissors,  as  this  sometimes  caused  troublesome 
hemorrhage.  The  stump  became  more  or  less  putrid,  and,  in  some  cases,  despite 
all  precautions,  a  distinct  odor  was  apparent.  After  the  clamp  was  removed  a 
large,  cone-shaped  hollow  was  left,  red  at  the  bottom  and  granulating.  A  con- 
siderable time  was  required  for  the  healing  of  this  hollow.  The  tissues  below 
gradually  retracted  and  the  new  scar  that  formed  over  the  surface  became  level 
with  the  skin.  This  hollow,  unfortunately,  formed  the  site  for  a  large  hernia  at  a 
subsequent  date. 

Such  an  operation  cannot,  by  any  means,  be  considered  ideal.  There  was 
constant  danger  that  some  of  the  septic  material  might  enter  the  abdominal  cavity. 
When  septic  peritonitis  did  occur,  it  usually  came  on  about  the  sixteenth  or  seven- 
teenth day,  just  when  the  operator  was  congratulating  himself  that  the  patient 
was  doing  well.  In  Cesarean  section  the  danger  occurs  within  the  first  two  or  three 
days.  In  Porro's  original  operation  the  danger  continued  until  after  the  clamp 
was  removed. 

There  is  also  the  danger  that  the  sloughing  process  may  not  be  confined  to  the  tis- 
sues on  the  distal  side  of  the  wire,  but  that  the  tissues  on  the  abdominal  or  proximal 
may  also  slough.  As  a  consequence  of  this  the  bladder  was  sometimes  entered 
or  one  of  the  ureters  injured.  Fortunately,  in  these  cases  the  uterine  tissue  is  elastic 
as  a  result  of  the  pregnancy,  and  the  sloughing  is  not  as  likely  to  occur  as  in  ordinary 
supravaginal  hysterectomy.  The  bladder  has  been  very  tightly  compressed  by  the 
serre-noeud  on  more  than  one  occasion. 

The  only  type  of  cases  in  which  the  extraperitoneal  treatment  of  the  stump  offers 
undoubted  advantages  is  when  the  uterus  is  virulently  infected  or  a  necrotic  and 
septic  tumor  is  present,  and  the  fetus  is  dead.  In  such  cases  by  employing  the 
extraperitoneal  method  the  uterus  need  not  be  opened  nor  the  fetus  extracted  until 
the  abdominal  wound  has  been  closed. 

In  the  light  of  modern  experience  the  intraperitoneal  treatment  of  the  stump 
is  the  one  which  should  be  employed.  This  treatment  was  not  successful  for  a  time, 
but  the  results  recently  obtained  fully  justify  us  in  using  this  method.  We  now 
know  that  if  great  care  is  taken  to  constrict  completely  the  uterine  and  ovarian 


104 


CESAREAN    SECTION    AND    PORRO-CESAREAN    SECTION. 


arteries  on  each  side,  all  subsequent  hemorrhage  can  be  controlled  by  the  appli- 
cation of  continuous  catgut  sutures  to  the  pedicle.  If  hemorrhage  is  not  controlled, 
it  is  because  the  uterine  arteries  have  not  been  properly  tied,  and  another  ligature 
must  be  placed  closer  to  the  cervix,  and  farther  down,  in  order  to  control  the  small 
branch  that  goes  to  form  the  circular  artery  and  to  anastomose  with  the  artery  on 
the  opposite  side.  Before  the  lower  sutures  of  catgut  are  placed  it  is  well  to  inspect 
the  stump,  as  it  frequently  happens  that  a  vessel  will  be  found  pumping  on  the 
anterior  cervical  wall,  owing,  no  doubt,  to  the  intimate  anastomosis  with  vesical 


Fig.  414. — Hernia  op  Pregnant  Uterfs  Owing  to  Separation  of  Recti  Muscles. 
Cervical  canal  pointing  upward  and  backward  (J.  F.  W.  Ross). 


branches,  and  another  on  the  posterior  wall  owing  to  its  connection  with  the  azygos 
vaginae  artery.     These  small  vessels  may  be  secured  with  catgut  sutures. 

After  the  operator  is  satisfied  that  there  is  no  hemorrhage  taking  place  from  the 
uterine  stump,  the  peritoneum  is  approximated  over  the  broad  ligaments  and  cervix 
so  that  the  intestines  do  not  come  into  contact  with  the  raw  surfaces.  This  can  be 
accompHshed  in  a  few  minutes,  and  is-  best  done  by  means  of  a  continuous  catgut 
suture.  The  technic  is  the  same  as  that  used  for  the  supravaginal  amputation  in 
hysterectomy  for  fibroid  tumors;  and  the  subsequent  course  is  also  similar  to 
that  of  hysteromyomectomy.     As  an  extra    precaution  against  peritonitis  from 


PORRO-CESAREAN  SECTION. 


105 


sloughing  of  the  cervix,  care  should  be  taken  in  suturing  the  peritoneum  over  the 
broad  ligaments  and  cervical  stump.  It  may  be  well  to  reinforce  the  peritoneal 
union  by  a  second  continuous  suture  above  the  cervix  itself  to  guard  against  leakage 
of  wound  secretions  into  the  peritoneal  cavity. 

Some  operators  prefer  to  puncture  the  vaginal  vault  and  drain  through  the  cul- 
de-sac  of  Douglas,  while  others  place  a  drainage-tube  from  the  abdominal  wound. 
The  drainage-tube  is  intended  to  act  as  a  sentinel,  and  I  believe  should  never  be 
omitted — in  this  respect  differing  from  most  of  my  colleagues.  The  tendency  among 
surgeons  is  to  avoid  drainage  in  non-septic  cases.  The  careful  ligation  of  vessels 
should  prevent  secondary  hemorrhage. 


Fig.  415. — Same  as  Fig.  414  after  Rupture  of  Vaginal  Wall  and  Extrusion  of  Fetus  and  Placenta  into 

Abdominal  Cavity. 
Note  empty  uterus  (J.  F.  W.  Ross). 


Figs.  414  and  415  illustrate  a  case  under  the  writer's  care  in  St.  Michael's 
Hospital,  Toronto,  seen  by  a  number  of  members  of  the  staff.  The  patient  had  a 
hernia  of  the  uterus  owing  to  separation  of  the  recti  muscles.  During  labor  the 
expulsive  efforts  forced  the  child  against  the  posterior  vaginal  wall  until  it  gave 
way  and  the  fetus  and  placenta  were  expelled  into  the  abdominal  cavity.  The 
abdomen  was  opened,  the  fetus  and  placenta  removed,  the  uterus  left  in  situ,  but 
the  patient  succumbed. 


CHAPTER  XXVIII. 

OPERATIONS  DURING  PREGNANCY. 
By  Richard  C.  Norris,  M.D. 

The  results  of  operations  on  pregnant  women,  within  the  period  of  aseptic 
surgery,  have  convinced  the  obstetrician  that  conservatism  often  means  prompt 
surgical  interference,  since  thereby  dangerous  complications  may  safely  be  removed 
and  maternal  and  fetal  life  be  saved. 

It  is  not  so  long  ago  that  the  prevailing  surgical  advice  was  to  operate  on  a  preg- 
nant woman  only  in  case  it  was  necessary  to  save  her  from  imminent  death  from 
the  gravest  conditions,  such  as  intestinal  obstruction,  strangulated  hernia,  or  intra- 
peritoneal hemorrhage.  The  experienced  surgeon  now  operates  when  he  desires 
to  obviate  dangers  to  the  mother  or  child  and  aims  to  prevent  not  only  complications 
dangerous  to  the  life  of  the  mother,  but  also  to  prevent  abortion  or  dystocia.  In 
the  presence  of  grave  intraperitoneal  infections,  and  for  certain  tumors  surgical  in- 
terference is  often  more  urgently  demanded  than  when  pregnancy  does  not  exist. 
The  latter  statement  is  particularly  applicable  to  acute  appendicitis,  ovarian  tumors, 
and  acute  infections  of  the  gall-bladder,  with  or  without  the  presence  of  calculi. 

Appendicitis. — Statistics  are  not  available  to  learn  the  relative  frequency  of 
the  occurrence  of  appendicitis  during  pregnancy  and  in  women  who  are  not  preg- 
nant. Treves^  notes  6  pregnant  women  among  1000  cases  of  operation  for  appen- 
dicitis; of  445  women  operated  upon  for  acute  appendicitis  at  the  German  Hos- 
pital, Philadelphia  (personal  communication  from  H.  F.  Page),  only  6  were  preg- 
nant. One  was  operated  upon  at  the  second  month  of  pregnancy,  two  at  the 
fourth  month,  two  at  the  sixth  month,  and  one  at  the  seventh  month.  All  the 
mothers  recovered;  two  miscarried,  one  at  the  second  and  one  at  the  sixth  month. 
Donaghue^  found  that  80  per  cent,  of  the  acute  cases  during  pregnancy  occurred 
during:  the  first  six  months. 

The  diagnosis  of  appendicitis  is  often  obscured  by  pregnancy.  Before  the  third 
month  the  uterus  fills  the  pelvis  and  makes  it  difficult  to  differentiate  between  the 
inflammations  of  the  appendix  and  of  the  right  tube  or  ovary.  After  the  third 
month,  when  the  uterus  has  left  the  pelvic  cavity,  right-sided  tubal  inflammation 
is  even  more  difficult  to  differentiate.  Nausea,  vomiting,  and  sudden  abdominal 
pain  are  frequently  associated  with  toxemia  of  pregnancy.  The  pain  of  appendi- 
citis during  pregnancy,  Pinard^  states,  is  usually  situated  over  the  attachments  of 

1  Treves,  Sir  F.:    "Appendicitis  after  Operation,"  British  Med.  Jour.,  March  4,  1905. 
^Donaghue,  F.  D.:    "Appendicitis  Complicating  Pregnancy,"  Boston  Med.  and  Surg.  Jour., 
vol.  cxlvii,  p.  279. 

3  Pinard,  Prof.  A.:   "Appendicite  et  grassessa,"  Bulletin  de  I'Acad.  de  M^d.,  Feb.  14,  1899. 

106 


APPENDICITIS.  107 

the  diaphragm,  and  the  pulse  and  temperature  may  show  httle  or  no  change.  The 
locaHzation  of  pain  in  the  region  of  the  hver  or  on  the  left  side  has  also  been  noted 
by  Zweifel.  When  pregnancy  is  advanced,  rigidity  of  the  right  side  of  the  abdomen 
is  not  prominent  or  it  may  be  absent.  Palpation  over  the  appendix  will  best  locate 
pain  and  tenderness,  when  the  patient  lies  on  her  left  side.  The  adhesions  that 
form  about  an  inflamed  appendix  may  fix  the  uterus,  prevent  its  proper  growth 
and  development,  and  terminate  pregnancy;  or  they  may  interfere  with  labor  and 
the  puerperium,  by  preventing  contractions,  causing  hemorrhage  or  subinvolution 
and  displacement.  Miscarriage  or  labor  may  cause  rupture  of  an  abscess  and  lead 
to  rapidly  fatal  peritonitis.  The  statistics,  the  clinical  and  the  pathologic  histories 
of  appendicitis  complicating  or  antedating  pregnancy,  clearly  prove  that  this  disease 
at  that  time  is  distinctly  more  dangerous,  and  that  early  diagnosis  and  surgical 
treatment  are  more  urgently  demanded  than  at  other  times.  The  dangers  are  so 
great  that  Webster^  asserts  that  a  woman  who  has  had  an  attack  of  appendicitis 
should  have  her  appendix  removed  before  pregnancy  is  permitted  to  occur. 

From  a  study  of  143  cases  occurring  during  pregnancy  and  the  puerperium, 
collected  by  Myer,^  it  appears  that  when  appendicitis  has  existed  prior  to  pregnancy, 
a  recurrent  attack  is  usual  and  is  liable  to  be  grave,  perforation  and  abscess  having 
occurred  in  50  per  cent,  of  such  cases.  The  greatest  danger  to  a  pregnant  woman 
stricken  with  this  infection  is  that  of  abscess  formation,  which  caused  abortion  in 
57  per  cent,  of  the  cases  collected,  regardless  of  the  treatment,  and  the  occurrence 
of  abortion  added  23  per  cent,  to  the  mortality  of  surgical  interference.  The  fre- 
quency of  the  occurrence  of  abortion  in  cases  not  operated,  was  stated  by  Fellner^ 
to  be  44  per  cent.;  while  following  operation  it  was  35  per  cent.  A  striking  fact 
is  noted  in  ]Myer's  statistics,  which  show  no  cases  of  interference  with  pregnancy 
in  17  cases  operated  upon  for  chronic  catarrhal  appendicitis.  The  frequency  of 
abortion  or  miscarriage,  whether  it  be  the  result  of  infection  spreading  to  the  uterus 
and  its  membranes  through  the  appendicular  and  broad  ligament  lymphatics, 
through  the  blood-current,  or  by  adhesions  or  abscess  formation  involving  the  pelvic 
organs  in  its  wall,  is  a  fact  that  warrants  surgical  interference,  at  the  earliest  period 
of  the  disease. 

If  operation  is  undertaken  promptly,  before  the  occurrence  of  gangrene, 
perforation  or  abscess  formation,  abortion  will  rarely  occur  and  recovery  is  the 
rule.  \Vhen  surgical  interference  has  been  delayed  and  the  above  named  compli- 
cations are  present,  operation  still  affords  the  best  prognosis  for  both  mother  and 
fetus.  Operations  during  the  early  months  are  more  favorable  than  those  during 
the  latter  months  of  pregnancy. 

Of  the  cases  collected  by  Myer  (loc.  cit.),  52  cases  were  not  treated  by  operation; 
of  these,  82  per  cent,  were  of  the  simple  catarrhal  form;  IS  per  cent,  developed 
abscesses,  of  whom  two-thirds  died,  and  one-third  recovered  by  spontaneous  rup- 

'  Webster,  J.  C:    "Operations  during  Pregnancy,"  Illinois  Med.  Jour.,  April,  1904. 

^Myer,  Max  W.:    "Appendicitis  Complicating  Pregnancy,"  Amer.  Jour.  Obst.,  March,  1906. 

^  Fellner,  A.  O.:  "Die  Chirurgie  in  der  Schwangerschaft,"  Centralbl.  f.  Gynak.,  Nr.  18,  1905. 


108  OPERATIONS   DURING    PREGNANCY. 

ture  of  the  abscess  into  an  adjacent  viscus.  In  25  per  cent,  pregnancy  was  inter- 
rupted;  the  total  maternal  mortality  was  14  per  cent. 

Of  69  cases  treated  by  operation,  gangrene  of  the  appendix  or  abscess  was  noted 
in  71  per  cent.;  16  per  cent,  of  the  cases  aborted  before  operation  and  37  per  cent, 
after  operation;   the  maternal  mortality  was  32  per  cent. 

Pinard^  has  reported  30  cases  with  a  mortality  of  33  per  cent. 

Boijee^  collected  31  cases  of  operation  for  acute  appendicitis  with  a  maternal 
mortality  of  41  per  cent.,  and  pregnancy  was  interrupted  in  58  per  cent.  These 
and  other  statistics  show  the  great  danger  to  the  fetus  and  to  the  mother  after  the 
occurrence  of  abscess,  and  point  to  early  operation  before  the  formation  of  pus  as 
the  only  means  of  diminishing  the  dangers  to  both  mother  and  fetus.  To  lessen 
the  risk  of  abortion,  the  uterus  should  be  disturbed  as  little  as  possible  during  the 
operation,  and  especially  when  it  happens  to  form  a  part  of  the  abscess  wall.  The 
removal  of  a  gauze  drain  is  liable  to  provoke  uterine  contractions  and  abortion,  and 
for  that  reason  when  drainage  is  required,  the  author  has  preferred  a  tube  or  a  con- 
dom drain.  Thorough  exploration  of  the  peritoneal  cavity  is  difficult  when  opera- 
tion is  performed  toward  the  end  of  gestation,  whether  the  incision  be  lateral  or 
median.  When,  late  in  pregnancy,  multiple  abscesses  are  suspected  and  the  uterus 
must  be  turned  out  of  the  incision,  Hirst^  has  called  attention  to  the  difficulty  of 
returning  the  uterus  through  the  wound  and  to  the  danger  of  the  wound  breaking 
open  within  a  few  hours  or  days  after  the  sutures  have  been  placed.  He  prefers 
for  these  reasons  to  do  a  Cesarean  section,  after  the  seventh  month  of  gestation,  as 
a  part  of  the  operation,  and  would  defer  operation,  if  possible,  until  the  uterus  has 
spontaneously  emptied  itself.  The  deliberate  emptying  of  the  uterus  prior  to  opera- 
tion has  had  a  high  mortality  and  should  be  abandoned.  The  practical  lesson 
to  be  learned  from  the  history  of  this  disease  in  pregnancy  is  that  early  diagnosis 
and  operation  are  paramount,  and  the  surgeon,  when  in  doubt,  ought  to  err  on  the 
side  of  safety  rather  than  to  wait  for  the  unmistakable  signs  of  perforation  or  abscess 
formation.  Even  when  these  have  occurred,  operation  offers  the  best  results  for 
mother  and  fetus,  but  it  should  be  remembered  that  such  delay  has  changed  a  rela- 
tively trivial  disease  into  a  disaster. 

Cholecystitis. — It  has  not  been  proved  that  pregnancy  predisposes  to  chole- 
lithiasis, as  asserted  by  Frerichs,  Fellner  collected  only  5  cases  in  40,000  patients 
in  Schauta's  clinic.  Kehr  has  stated  that  10  per  cent,  of  women  in  the  child-bear- 
ing period  of  life  have  gall-stones.  On  theoretic  grounds,  therefore,  pregnancy  and 
labor  have  no  close  relation  to  inflammation  of  the  gall-bladder.  The  cases  reported 
by  Pinard*  and  by  Christiani^  indicate  that  early  operation,  as  in  appendicitis,  is 

^  Pinard,  Prof.  A.:  "De  la  appendic.  dans  ses  rapports  avec  la  puerperalite,"  Ann.  de 
Gynec,  Tome  xlix,  li,  liii. 

2  Boijee,  O.  A.:  "Zur  ventrofix.  der  prolabirten  GelDtlrmutter,"  Mittheil.  aus  der  Gyn.  Klinik 
der  Professor  Engstrom,  Bd.  ii,  H.  1. 

^  Hirst,  B.  C.:   "Pseudomyxoma  Peritonei,"  Amer.  Jour.  Obst.,  March,  1906. 

*Pinard,  M.  A.:    "Cholecystite  et  puerperalite,"  Ann.  de  Gynec,  April,  1903. 

^  Christiani:  "Cholecystitis  im  Wochenbett,"  Monatsch.  f.  Geburtsh.  u.  Gynak.,  Bd.  xxi, 
Hft.  1. 


FIBROID   TUMORS    OF   THE    UTERUS.  109 

more  urgently  demanded  during  pregnancy  than  at  other  times.  During  the 
puerperal  period  infection  of  the  gall-bladder  may  be  associated  or  confused  with 
puerperal  sepsis. 

Fibroid  Tumors  of  the  Uterus.— The  life-history  of  uterine  fibroids  compli- 
cating pregnancy  shows  that  approximately  in  75  per  cent,  of  the  eases  the  course 
of  pregnancy,  labor,  and  the  puerperium  is  undisturbed.  Very  commonly  there 
is  a  readjustment  of  the  tumor  before  the  end  of  pregnancy  or  even  during  labor, 
and  the  pelvic  canal  threatened  with  obstruction,  is  freed  for  the  passage  of  the 
child.  Of  5500  patients  delivered  in  the  General  Lying-in  HospitaP  there  was  no 
instance  of  obstruction  to  laljor  caused  by  uterine  fibroids.  Budin  in  the  Paris 
Maternite,  and  Porak  and  ^Nlace,  in  the  Charite,  have  recorded  similar  experiences. 
Of  2500  deliveries  under  the  author's  care  at  the  Preston  Retreat,  there  have  been 
but  two  cases  of  uterine  fibroids  that  gave  promise  of  obstructing  labor.  Both 
cases  were  prepared  for  Cesarean  section  should  the  test  of  labor  fail  to  remove  the 
obstruction,  and  in  both  instances  spontaneous  labor  occurred,  followed  by  normal 
lying-in  periods.  Winter  studied  23  cases  of  pregnancy  complicated  by  fibroids, 
and  observed  that  5  progressed  without  any  disturbance;  18  had  varying  degrees 
of  pain  and  discomfort  due  to  various  causes,  such  as  painful  uterine  contractions, 
localized  peritonitis,  or  secondary  changes  in  the  tumor.  Of  14  cases  treated 
expectantly,  9  terminated  naturally,  3  aborted,  2  had  premature  labors.  One 
case  required  forceps,  and  one  manual  removal  of  the  placenta.  Six  cases  were 
operated  upon,  of  which  4  were  radical  and  2  conservative.  This  rather  remark- 
able freedom  from  complications  at  labor  and  during  pregnancy  does  not,  however, 
do  away  with  the  necessity  for  constant  observation  of  the  patient  and  of  her  tumor 
throughout  the  course  of  her  pregnancy,  since  the  many  changes  that  recent  inves- 
tigation has  shown  to  occur  in  fibroid  tumors  have  not,  so  far  as  the  author  is  aware, 
been  proved  to  occur  less  frequently  when  the  tumor  is  associated  with  pregnancy. 
On  the  contrary,  some  of  the  changes  are  notably  more  prone  to  occur  at  that  time. 

Rapid  growth  of  the  tumor,  whether  from  hypertrophy  or  edema,  may  cause 
pain,  serious  pressure  upon  the  bladder,  impaction  of  the  tumor  or  the  uterus  in  the 
pelvis,  or  may  occasion  excessive  rotation  of  the  uterus  and  thus  interfere  with  fetal 
grow^th  and  development  and  cause  abortion  and  premature  labor.  Localized 
peritonitis  with  adhesions,  blood  extravasations  into  the  tumor,  necrosis,  degenera- 
tive changes,  and  even  suppuration  and  fatal  peritonitis  are  more  serious  compli- 
cations. During  labor,  while  obstruction  is  rare  because  the  tumors  are  situated 
in  the  upper  segment  of  the  uterus  and  commonly  subperitoneal,  hemorrhage  from 
placenta  prsevia  or  submucous  tumors  and  mal-presentations  are  not  so  uncommon, 
and,  after  delivery,  retention  of  the  placenta,  requiring  manual  removal,  post- 
partum hemorrhage,  necrosis  or  infection  of  the  tumor  may  jeopardize  the  patient's 
life.     The  fact  that  so  many  women  with  fibroids  go  through  pregnancy  and  labor 

'  Dakin,  W.  R.:  "Effect  of  Childbearing  on  Fibroid  Tumors  of  the  Uierus,"  Jour,  of  Obst. 
and  Gynec.  of  the  Brit.  Empire,  August,  1904. 

^  Winter,  A.:   "  Myom  und  Graviditat,"  Monatsch.  f.  Geburtsh.  u.  Gynak.,  Bd.  xx,  S.  263. 


110  OPERATIOXS   DURING    PREGXAXCY. 

without  complications  does  not  remove  the  necessity  for  careful  and  unremitting 
supervision  of  each  individual  case  in  order  to  avert  disaster  by  prompt  operation. 
When  there  are  no  symptoms  produced  by  the  tumor  before  the  fetus  has  reached  a 
viable  age,  the  most  important  and  often  a  difficult  problem  is  to  determine  whether 
or  not  the  tumor  will  obstruct  labor.  Tumors  situated  above  the  supravaginal 
cemx  (the  obstetric  upper  uterine  segment)  never  offer  obstruction  except  those 
with  long  pedicles,  and  these  can  usually  be  replaced  by  gently  lifting  them  out  of 
the  peh'is,  if  the  displacement  is  detected  early  and  before  impaction.  Tumors 
located  in  the  supravaginal  cer\'ix,  if  anterior,  almost  never  obstruct  labor.  The 
writer  has  repeatedly  observed  them  grow  above  the  pelvic  brim  during  pregnancy 
and  have  no  ill  effect  upon  either  labor  or  the  puerperium.  When  located  poste- 
riorly their  rapid  growth  may  lead  to  impaction  with  adhesions,  the  tumor  having  been 
caught  below  the  sacral  promontory.  In  three  such  cases  the  writer  has  removed 
the  impacted  tumor  by  abdominal  myomectomy  without  interrupting  pregnancy. 
Intraligamentary  and  cervical  fibroids  are  most  likely  to  cause  obstruction,  since  one 
cannot  expect  them  during  labor  to  be  drawn  upward  and  away  from  the  birth  canal 
by  the  longitudinal  fibers  of  the  lower  uterine  segment.  The  old  practice  of  forcible 
attempts  to  dislodge  a  pehac  bound  tumor  by  pressure,  manual  or  hydrostatic,  with 
or  without  an  anesthetic,  must  be  abandoned.  ^Mistaken  diagnosis,  grave  accidents, 
and  surgical  tragedies  have  often  resulted  from  such  treatment,  and,  contrasted  with 
the  excellent  results  of  elective  surgery,  one  can  only  conclude  that  forcible  re- 
placement should  never  be  attempted.  The  results  of  inducing  abortion  are  almost 
equally  disastrous,  and  should  also  be  abandoned,  except  in  the  rare  instances 
when  anesthesia,  general  or  spinal,  cannot  be  used  or  when  a  tumor  is  so  situated, 
as  an  interstitial  growth  near  the  cervix,  that  by  inducing  abortion  a  subsequent 
myomectomy  may  be  more  safely  done  and  a  future  pregnancy  be  unobstructed. 

Experience  has  shown  it  best  to  allow  pregnancy  complicated  by  fibroid  tumors 
to  continue  so  long  as  urgent  symptoms  are  absent  and  to  operate  on  obstructive 
cases  a  few  days  before  term.  If  the  case  presents  any  prospects  of  relief  from  the 
obstruction  by  uterine  contractions  during  labor,  and  the  patient  can  be  placed  in  a 
surgical  environment  affording  facilities  for  operation  at  any  time,  as  in  a  hospital, 
the  operation  may  be  performed  after  the  test  of  labor.  It  is  well  to  remember, 
in  all  cases  progressing  favorably,  that  labor  not  infrequently  occurs  prematurely, 
and  provision  should  be  made  for  such  an  emergency. 

Having  delivered  the  child  by  Cesarean  section,  if  conditions  specially  favorable 
for  myomectomy — a  single  or  very  few  and  small  additional  pedunculated  tumors — 
are  present,  that  operation  may  be  selected.  Usually  the  dangers  of  hemorrhage 
from  faulty  contraction  of  the  uterus,  of  insecure  stitches  in  an  irregular  incision 
made  necessary  by  multiple  and  sessile  growths,  will  indicate  the  necessity  for 
hysterectomy.  At  term  a  cervical  fibroid  can  often  be  enucleated  and  removed 
per  vaginam  and  the  delivery  at  once  accomplished  by  forceps  or  version.  During 
pregnancy  when  the  rapid  growth  of  multiple  tumors  or  a  single  pelvic  bound  tumor 
produces  grave  pressure  symptoms  threatening  fetal  life,  or  the  mother's  life  is 
jeopardized  by  degenerative  processes  in  the  tumors,  or  her  heart  and  excretory  organs 


AMPUTATION    OF    CERVIX  FOR   HYPERTROPHY   OF   VAGIXAL    PORTION.  Ill 

show  signs  of  failing  power,  delay  is  dangerous,  and  myomectomy  or  hysterectomy 
are  the  operations  to  be  considered.  There  has  been  considerable  controversy  as 
to  the  respective  merits  of  these  operations  during  pregnancy,  and  before  discussing 
them  the  author  is  constrained  to  state  his  conviction  that  the  limited  field  of  mvo- 
mectomy  has  even  greater  restrictions  during  pregnancy.  For  the  relief  of  pressure 
symptoms  before  viability  of  the  fetus  it  is  the  ideal  operation  for  a  single  peduncu- 
lated or  sessile  tumor  with  a  narrow  and  shallow  base.  Large  interstitial  growths, 
the  variety  most  likely  to  take  on  rapid  growth  during  pregnancy  and  to  encroach 
upon  the  uterine  cavity,  or  multiple  tumors  requiring  many  incisions,  increase  the 
danger  of  insecure  stitching  following  abortion  which  is  frequent  after  the  removal 
of  such  tumors,  and  render  the  operation  under  those  conditions  distinctly  more 
dangerous  than  hysterectomy.  Although  it  is  argued  that  the  special  justification 
of  myomectomy  is  the  saving  of  fetal  life,  the  added  risk  to  the  mother  and  the 
frequency  of  abortion  following  myomectomy  do  not  warrant  its  selection  except 
under  the  most  favorable  conditions  as  noted  above.  Stavely  studied  the  results 
in  32  cases,  and  found  abortion  followed  in  30.3  per  cent.,  the  maternal  mortality 
between  1885  and  1889  being  IG.SS  per  cent. ;  between  1889  and  1894, 11.75  per  cent. 

J.  Duncan  Emmett^  collected  44  cases  between  1890  and  1900  that  gave  a  mater- 
nal  mortality  of  9  per  cent,  and  a  fetal  mortality  of  21  per  cent.  Winter^  more  re- 
cently, however,  reports  only  11  abortions  following  58  cases  of  subsero-interstitial 
tumors,  and  states  his  belief  that  pregnancy  in  no  respect  adds  to  the  mortality  of 
myomectomy.  Statistics,  after  all,  are  often  misleading,  and  careful  perusal  of 
the  histories  of  individual  cases  has  convinced  the  writer  that  it  is  very  seldom  justi- 
fiable to  depart  from  the  usual  contraindications  of  myomectomy  and  thus  add  a 
risk  to  maternal  life  in  order  to  gain  an  uncertain  advantage  for  the  fetus.  Each 
case  when  brought  to  operation  must  be  a  law  unto  itself,  and  only  when  the  oper- 
ator's skill  and  judgment  plainly  indicate  the  safety  of  myomectomy  should  that 
operation  be  performed.  It  is  in  those  cases  when  the  usual  contraindications  have 
been  abandoned  with  the  hope  of  saving  the  child  that  the  maternal  mortality  of 
myomectomy  has  been  greatest. 

Cervical  polyps,  mucous  or  fibroid,  rarely  cause  abortion  when  removed  during 
pregnancy,  and  with  care  not  to  injure  the  amniotic  sac  they  may  be  removed  at 
any  period  of  pregnancy. 

Amputation  of  the  Cervix  for  Hypertrophy  of  the  Vaginal  Portion. — The 
prognosis  of  this  complication  is  grave  for  both  the  mother  and  the  child.  The 
obstacle  to  dilatation  makes  the  length  of  labor,  with  the  usual  premature  rupture 
of  the  membranes,  a  distinct  danger  to  the  cliild,  and  to  effect  delivery  deep  incisions 
into  the  cervix  followed  by  forceps  extraction  or  vaginal  or  abdominal  Cesarean 
section  may  be  required.     Potocki^  has  shown  that  grave  accidents  are  common 

^  Emmett,  J.  Duncan:  "  Myomectomy  Durins:  Presnancy,"  Amer.  Gyn.  and  Obst.  Jour..  June, 
1901. 

^Winter:  "  Die  wissenschaftlichen  Grundlagen  der  Conseryatiye  Myomoperation."  Zeitschr. 
f.  Geburtsh.  u.  Gynak.,  Bd.  li,  Nr.  5. 

^  Potocki :  "  De  Tamputation  du  col  pendant  la  grossesse  dans  le  cas,"  Ann.  de  Gyn.  et  d'Ob- 
stet.,  1906,  iii,  709. 


112 


OPERATIONS   DURING    PREGNANCY. 


enough  to  justify  interference  before  pregnancy  is  well  advanced.  He  collected 
eight  cases  of  amputation  during  pregnancy  with  only  one  abortion  following  the 
operation.  The  amputation  should  secure  perfect  coaptation  without  subsequent 
cicatrices,  should  be  done  in  the  fourth  month  of  pregnancy,  when  abortion  is  least 
likely  to  be  produced,  and  the  uterus,  during  the  operation,  should  not  be  forcibly 
dragged  into  the  vagina. 

Ovarian  Tumors. — Pregnancy,  as  a  rule,  does  not  cause  the  increase  in  growth 
observed  in  uterine  fibroids,  but  some  of  the  complications  that  may  arise  in  the 
life-history  of  ovarian  tumors  are  more  likely  to  occur  during  pregnancy.  This  is 
true  of  attacks  of  peritonitis  followed  by  adhesions,  and  of  torsion  of  the  pedicle, 
which  is  especially  liable  to  occur  when  the  tumor  is  situated  above  the  pelvic  brim, 
and  particularly  in  the  puerperal  period,  when  the  frequency  of  this  accident  is 
increased  threefold.  Pressure  symptoms  are  aggravated,  and  rupture  and  suppura- 
tion, the  latter  being  more  likely  in  dermoid  tumors,  are  accidents  more  commonly 
observed  when  the  tumors  are  small  and  remain  in  the  pelvic  cavity,  often  undiscov- 
ered until  acute  symptoms  occur.  In  an  admirable  study  of  this  subject  compris- 
ing a  series  of  1290  cases  McKerron^  found  one  in  four  ovarian  tumors  complicating 
pregnancy  to  be  dermoid,  and  from  their  greater  liability  to  remain  in  the  pelvis 
(three  out  of  every  five  cases)  they  are,  next  to  cancerous  growths,  distinctly  the 
most  dangerous  variety.  Swan^  could  find  only  14  undoubted  cases  of  solid  tumors 
of  the  ovary  complicating  pregnancy.  Including  malignant  growths,  serious  com- 
plications during  pregnancy,  labor,  or  the  puerperal  period  may  be  expected  in 
from  25  to  30  per  cent,  of  all  cases,  and  from  16  to  20  per  cent,  of  the  pregnancies 
will  terminate  prematurely. 

Adding  thereto  the  dangers  to  the  child  from  operative  deliveries  necessitated 
at  term,  the  infant  mortality  rises  to  30  or  35  per  cent.  Ml  Kerron's  tables  show 
that  in  720  cases  not  operated  upon  the  maternal  mortality  is  21  per  cent.,  the  fetal 
30  per  cent.  Of  recent  cases  collected  by  him,  the  results  of  operation  are  shown 
in  the  following  tables: 

RECENT  CASES  (OPERATEON);    MATERNAL  AND  FETAL  MORTALITY. 


Pregnancy  Interrupted  and 

Child  Lost. 

Month  of 

Number 

Maternal 

Percent- 

Number 

Pregnancy. 

OF 

Operations. 

Deaths. 

age 
Mortality. 

OF 

Operations. 

All  Cases. 

Excluding 
Complicated 

Cases. 

Per  cent. 

Per  cent. 

Second 

28 

0 

0.0 

28 

6         20.7 

5         18.5 

Third 

62 

2 

3.2 

60 

9         15.0 

5           8.8 

Fourth 

62 

3 

4.8 

60 

7         11.6 

3           5.3 

Fifth 

41 

2 

4.8 

38 

8         21.0 

2           6.2 

Sixth 

22 

0 

0.0 

22 

8         36.3 

4         22.2 

Seventh 

15 

1 

6.6 

15 

5         33.3 

3         20.0 

Eighth 

7 

0 

0.0 

7 

4         57.1 

4         57.1 

Ninth 

7 

0 

0.0 

6 

0           0.0 

0           0.0 

1  McKerron,  R.  G.:  "  Pregnancy,  Labour  and  Child-Bed  with  Ovarian  Tumour,"  London,  1903. 
^  Swan,  Wm.  E.:  "  Tumors  of  Ovary  Complicating  Pregnancy,"  Johns  Hopkins  Hosp.  Bull., 
March,  1898. 


VAGINAL    FISTULA.  113 

During  the  twelve  years  preceding  1903,  he  collected  299  ovariotomies  during 
pregnancy  and,  although  in  many  of  these  acute  symptoms  existed  at  the  time  of 
operation,  the  mortahty  was  3.3  per  cent.  Omitting  the  unavoidable  deaths,  the 
mortality  was  2.3  per  cent.  In  his  total  series  of  cases  pregnancy  was  interrupted 
in  20  per  cent.  When  no  complications  existed  at  the  time  of  operation  the  pro- 
portion was  11  per  cent.  In  94  labors  obstructed  by  pelvic  ovarian  tumors  the 
maternal  mortality  was  9.5  per  cent.,  and  in  50  abdominal  ovarian  tumors  not 
operated  on  during  pregnancy  the  mortality  was  10  per  cent.  The  only  conclu- 
sions possible  from  these  results  are  that  when  no  other  complication  exists  preg- 
nancy at  any  period  may  be  disregarded  as  a  factor  in  maternal  mortality,  and  that 
ovariotomy  under  the  conditions  just  noted,  and  even  when  premature  termination 
of  pregnancy  is  threatened,  adds  practically  no  danger  to  fetal  life.  A  careful 
study  of  this  subject  from  every  viewpoint  of  either  the  abdominal  surgeon  or  the 
obstetrician  will  convince  both  of  the  desirability  of  the  early  recognition  and  removal 
of  an  ovarian  tumor  complicating  pregnancy.  Operations  performed  during  the 
third  or  fourth  month  have  given  the  best  results.  The  older  methods  of  treatment, 
tapping  or  the  induction  of  abortion  or  premature  labor,  are  almost  never  to  be 
employed,  and  can  only  be  considered  under  the  most  exceptional  conditions.  The 
former  will  best  conserve  the  child's  interest,  when,  late  in  pregnancy,  a  monocyst, 
firmly  adherent  to  the  uterus,  can  be  temporarily  relieved  and,  the  child  having 
been  delivered,  the  cyst  should  be  removed  immediately  after  labor.  The  induction 
of  abortion  or  premature  labor  will  be  justified  only  in  the  presence  of  grave  systemic 
or  advanced  malignant  disease  that  contraindicates  ovariotomy. 

During  an  operation  for  the  removal  of  an  ovarian  tumor  complicating  preg- 
nancy, and  especially  if  abortion  or  labor  is  imminent,  the  least  possible  manipula- 
tion of  the  uterus  is  desirable.  When,  however,  the  tumor  is  pelvic  bound,  the 
uterus,  protected  with  gauze  and  warm  salt  solution,  should  be  turned  out  through 
the  incision  to  favor  enucleation  of  the  cyst.  The  opposite  ovary  should  always  be 
examined.  The  usual  care  not  to  rupture  a  dermoid  cyst,  its  relative  frequency 
and  cause  of  acute  symptoms,  should  place  the  operator  on  guard  for  this  variety 
of  tumor.  In  difficult  enucleation  if  the  uterine  wall  is  seriously  torn  and  the  mem- 
branes are  penetrated.  Cesarean  section  should  be  resorted  to  at  once.  The  dangers 
of  infection  should  abortion  occur,  and  the  difficulty  of  dealing  with  adhesions  or 
hemorrhage,  render  the  abdominal  operation  safer  than  operation  per  vaginam. 

Vaginal  Fistulae. — A  fistulous  opening  into  either  the  bladder  or  rectum  is 
an  unfortunate  complication  of  pregnancy  and  may  prove  a  danger  at  the  time  of 
labor  or  during  the  puerperium.  This  is  especially  true  of  large  openings,  whether 
vesicovaginal  or  rectovaginal,  and  numerous  cases  of  their  repair  during  pregnancy 
without  the  occurrence  of  abortion  make  these  operations  justifiable  to  prevent  the 
danger  of  infection  at  delivery  or  during  the  lying-in  period.  Noble  (personal 
communication)  has  operated  on  one  case  of  large  vesicovaginal  fistula  with  satis- 
factory union  and  without  interruption  of  the  pregnancy.  Repair  of  a  laceration 
of  the  sphincter  ani  muscle  during  pregnancy  has  also  been  frequently  performed 

VOL.  II — 8 


114  OPERATIONS   DURING    PREGNANCY. 

with  success.  Although  the  presence  of  fecal  discharges  at  the  vaginal  introitus 
adds  a  risk  of  infection  from  examinations  during  labor  and  from  contamination 
during  the  puerperium,  these  dangers  may  be  avoided  with  due  care.  It  has,  there- 
fore, seemed  unnecessary  to  the  writer  to  repair  a  lacerated  sphincter  during  preg- 
nancy. Moreover,  the  Hability  of  the  recently  formed  scar  tissue  to  give  way  in  the 
perineal  stage  of  labor  renders  the  operation  less  desirable  than  in  the  late  puer- 
perium. 

Urinary  Tract. — A  vesical  calculus  complicating  pregnancy  should  be  removed 
at  the  earliest  possible  period  of  pregnancy.  If  its  size  does  not  permit  removal 
through  a  speculum  after  safe  dilatation  of  the  urethra,  lithotripsy  or  vaginal  lithot- 
omy is  indicated. 

Ureteritis,  Pyelitis,  and  Pyonephrosis. — Infection  of  the  ureter  and  pelvis 
of  the  kidney  during  pregnancy  may  not  be  preceded  by  cystitis.  The  important 
factor  is  believed  to  be  compression  of  the  ureter  by  the  pregnant  uterus,  predispos- 
ing to  infection  of  the  ureter,  very  often  by  the  colon  bacillus,  or  less  frequently 
by  other  bacteria.  Appendicitis,  salpingitis,  and  typhoid  fever  are  conditions 
that  may  confuse  the  diagnosis.  Opitz^  analyzed  64  cases.  The  right  side  was 
more  frequently  involved,  due  in  part  to  the  course  of  the  right  ureter.  The  symp- 
toms occur  most  frequently  during  the  fifth  to  the  seventh  month.  Of  18  cases 
collected  by  Smith,^  the  results  in  15  were  as  follows:  in  11  the  course  of  pregnancy 
was  unaffected,  the  pus  disappearing  from  the  urine  in  8  of  them  before  labor;  4 
cases  miscarried,  the  temperature  in  three  of  these  having  risen  to  104°  F.  In  two 
cases  the  pyelitis  progressed  to  pyonephrosis  after  labor.  One  recovered  from  ne- 
phrectomy four  months  after  labor  (colon  bacillus  infection) ;  the  other  died  after 
nephrotomy,  pyonephrosis  being  found  on  one  side  and  hydronephrosis  on  the  other. 
The  necessity  for  terminating  pregnancy  or  for  surgical  treatment  is  not  universally 
recognized.  Usually  pyelitis  will  improve  when  treated  by  milk  diet,  urinary 
antiseptics,  and  relief  from  pressure,  in  the  early  months  by  a  pessary,  in  the  later 
months  by  posture  (Trendelenburg  or  periods  of  the  knee-chest  posture).  When 
the  case  becomes  threatening  before  the  period  of  viability  of  the  child,  the  induction 
of  abortion  or  surgical  treatment  is  necessary.  Distinct  enlargement  of  the  kidney 
or  its  pelvis  always  calls  for  interference.  Nephrotomy  and  nephrectomy  have 
been  recommended,  and  have  been  successful  in  saving  fetal  life,  as  in  the  cases 
reported  by  Kendirdjy,^  and  by  Sippel,*  but  most  obstetric  surgeons  prefer  to  ter- 
minate pregnancy  and  operate  subsequently  if  necessary.  Ten  successful  preg- 
nancies following  removal  of  one  kidney  have  been  collected  by  Noble.^  In  these 
cases  the  one  kidney  has  gradually  gained  its  compensatory  excretory  power  and 

1  Opitz,  E.:   "  Treatment  of  Puerperal  Pyemia,"  Deutsch.  med.  Wochenschr.,  1904,  Nr.  51. 

2  Smith,  G.  B.:  "  Pyelitis  in  Pregnancy,"  Jour,  of  Obst.  and  Gyn.  of  the  Brit.  Empire,  August, 
1905. 

^  Kendirdjy,  L^on:  "  Des  py^lon^phrites  de  grossesse,"  Gaz.  des  Hopiteaux,  1904,  No.  41,  p. 
393,  and  No.  44,  p.  425. 

^  Sippel,  A.:  "  Pyonephrosis,  PveUtis  und  Harnleiterkompression  wahrend  des  Schwanger- 
schaft,"  Zentralbl.  f.  Gynak.,  1905,  Nr.  37. 

^  Noble,  Chas.  P.:   "Nephrectomy  followed  by  Pregnancy,"  American  Medicine,  May,  1906. 


MALIGNANT   GROWTHS.  115 

has  been  equal  to  the  demands  of  subsequent  pregnancy.  The  increased  danger 
of  the  stress  thrown  suddenly  on  the  remaining  kidney  during  pregnancy  has  led 
most  obstetricians  to  prefer  the  induction  of  labor,  which  often  removes  the  necessity 
for  surgical  treatment. 

Affections  of  the  Vulva. — Cysts  of  the  vulva,  if  large  or  growing  rapidly,  should 
be  excised,  and  the  wound  closed  if  there  is  sufficient  time  to  obtain  union  before 
the  onset  of  labor.  At  term  evacuation  and  drainage  by  means  of  a  gauze  pack  are 
preferable. 

Abscess  of  Bartholin's  gland  should  be  freely  incised,  the  gland  excised  if  possible, 
and  after  disinfecting  the  wound  it  may  be  partially  closed  and  drained.  The 
possibility  of  infection  during  and  after  labor  renders  this  complication  near  the 
end  of  pregnancy  a  serious  one,  and  adds  distinct  dangers  to  vaginal  examinations 
or  operative  delivery. 

Hematoma  of  the  vulva,  if  large  or  suppurating,  should  be  opened  and  drained. 

Pelvic  Inflammations. — Acute  pelvic  inflammations  complicating  pregnancy 
are  very  rare.  Spontaneous  abortion  is  usual,  and  prompt  operation  may  save 
fetal  life.  Pregnancy  and  localized  pelvic  inflammation  will  have  a  history  of 
excessive  pain  and  often  of  repeated  miscarriage,  and  require  a  careful  examina- 
tion, usually  with  the  patient  anesthetized.  If  a  mass  is  discovered,  or  the  uterus 
is  displaced  and  held  by  firm  adhesions  which  resist  judicious  efforts  for  replace- 
ment, operation  is  indicated.  Impaction  or  incarceration  of  the  gravid  uterus  is 
also  best  treated  by  abdominal  section  when  gentle  efforts  or  hydrostatic  pressure 
have  failed.  Forcible  reposition  should  never  be  employed;  Jacobs,  Mann,  and 
others  have  reported  brilliant  results  following  abdominal  operation  for  these  cases. 
Neglected  cases  of  impaction  of  the  uterus,  with  necrotic  or  gangrenous  changes 
in  the  uterus  or  bladder,  add  great  danger  to  abdominal  operative  treatment,  and, 
like  a  large  pelvic  abscess  complicating  pregnancy,  will  sometimes  be  better  treated 
by  inducing  abortion  and  subsequently  draining  the  pelvis  per  vaginam. 

Malignant  Growths. — Carcinoma  of  the  Cervix. — The  surgical  treatment  of 
malignant  disease  of  the  cervix  complicating  pregnancy  depends  upon  the  progress 
of  the  disease  and  the  period  of  pregnancy  when  recognized.  In  the  first  half  of 
pregnancy  an  operable  case  is  best  treated  by  vaginal  hysterectomy;  after  the 
fifth  month,  by  abdominal  complete  hysterectomy,  or  the  uterus  may  be  emptied 
and  removed  by  vaginal  hysterectomy — the  most  recent  technic  being  that  of  Diihrr- 
sen,  and  named  by  him  vaginal  Cesarean  section.  An  inoperable  case  permitted 
to  go  to  term  in  the  child's  interest  may  require  Cesarean  section  followed  by  the 
usual  palliative  treatment. 

Operable  carcinoma  of  the  rectum  requires  the  induction  of  abortion  and  later 
the  removal  of  the  rectum.  Inoperable  cases,  if  the  fetus  is  living,  will  require 
Cesarean  section  at  term.  Nijhoff^  has  reviewed  26  cases.  In  Kjelberg's  case  the 
growth  was  extirpated  at  the  fourth  month  without  interrupting  pregnancy.  Peter- 
sen's case  aborted  four  days  after  extirpation  and  died  the  following  day  of  peri- 
*  Nijhoff,  G.  C:   Schwangerschaft  und  Carcinoma  recti,"  Zentralbl.  f.  Gynak.,  Nr.  28,  1905. 


116  OPERATIONS    DURING    PREGNANCY. 

tonitis.  Extirpatiqii  several  days  after  induced  abortion  has  given  the  best 
results. 

Dental  Operations. — Dentists  usually  follow  the  rule  that  only  temporary 
operations  upon  the  teeth  should  be  undertaken  during  pregnancy,  and  recognize 
that  intense  pain  and  shock  are  especially  dangerous.  Custer^  discusses  this  sub- 
ject and  states  that  non-interference  in  serious  cases,  such  as  difficult  cavities  with 
exposed  pulps,  phagedenic  pericementitis,  abscess,  impacted  third  molars,  can 
produce  abortion,  and  that  operation  for  their  relief  and  cure  is  indicated,  an  anes- 
thetic being  employed  to  avoid  shock. 

Oakman"  also  believes  that  it  would  be  unwise  to  allow  a  woman  to  suffer  from 
neuralgia,  odontalgia,  alveolar  abscess,  carious  bone,  or  diseased  antrum,  which 
cause  great  pain  or  suppuration.  Temporary  operations  are  especially  to  be  em- 
ployed in  cases  of  highly  sensitive  and  neurasthenic  women.  Prolonged  sittings, 
great  pain,  anxiety,  and  shock  are  always  to  be  avoided. 

Preliminary  and  Post-operative  Precautionary  Management. — Increased 
irritability  of  the  nervous  system  during  pregnancy,  and  of  the  uterus  at  the  men- 
strual epochs,  has  doubtless  some  relation  to  the  occurrence  of  abortion  after 
surgical  operations.  A  hopeful  and  encouraging  attitude  of  the  surgeon,  the  use  of 
nerve  sedatives,  and,  when  possible,  the  selection  of  a  time  for  operation  when  the 
patient  is  not  in  or  near  a  menstrual  epoch  are  desirable  precautionary  measures. 
To  avoid  the  stage  of  excitation  of  etherization,  chlorid  of  ethyl  may  be  used,  and 
is,  on  theoretic  grounds,  less  dangerous  to  the  fetus  than  the  asphyxia  of  nitrous 
oxid  gas.  Intraperitoneal  operations  should  be  conducted  through  the  smallest 
incision  compatible  with  rapid  and  thorough  work,  and  especially  should  the  preg- 
nant uterus  be  handled  as  little  as  possible.  Rather  than  prolong  the  manipula- 
tion of  the  uterus  it  is  better  to  at  once  enlarge  the  incision,  gently  turn  the  uterus 
out  through  the  wound,  and  wrap  it  in  gauze  wet  with  warm  salt  solution,  in  order 
to  facilitate  the  quick  removal  of  a  pelvic  bound  growth.  Following  an  operation 
of  any  magnitude,  chloral  or  bromids  to  allay  nervousness,  and  especially  opium 
and  viburnum  prunifolium  in  full  physiologic  doses  for  several  days,  are  of  un- 
doubted value  to  diminish  the  risk  of  abortion  or  premature  labor.  After  abdominal 
operations  in  which  gauze  drainage  has  been  used,  the  removal  of  the  latter,  espe- 
cially when  adjacent  to  the  uterus,  will  excite  uterine  contractions  and  may  provoke 
an  abortion  or  premature  labor.  The  condom  or  cigarette  drain  will  prevent  firm 
adhesions,  and  is  therefore  preferable  when  gauze  drainage  is  required.  The 
uterine  sedatives  above  referred  to  should  be  continued  until  the  drainage  appliances 
have  been  removed.  To  insure  firm  union  of  the  abdominal  wound  and  to  fortify 
the  scar  against  the  unusual  stretching  incident  to  pregnancy,  it  is  desirable  to  have 
the  patient  rest  in  bed  for  three  weeks  after  the  operation  and  to  wear  a  properly 
fitted  abdominal  supporter  throughout  the  pregnancy. 

^  Custer,  H.  T.:   "Dental  Operations  during  Pregnancy,"  Dental  Cosmos,  vol.  xxxix,  p.  154. 
^  Oakman,  C.  H.:   "Dental  Treatment  during  Pregnancy,"  Dental  Cosmos,  vol.  xlvi,  p.  495. 


CHAPTER  XXIX. 

THE  OPERATIVE  TREATMENT  OF  SEPSIS  IN  THE  CHILD-BEARING 

PERIOD. 

By  Barton  Cooke  Hirst,  M.D. 

The  medical  treatment  of  puerperal  sepsis  has  already  been  discussed  in  Chap- 
ter IV,  Vol.  I.  The  operative  treatment  of  this  condition  comprises,  first,  the  routine 
instrumental  exploration  of  the  uterus;    second,  vaginal  section;    third,  celiotomy. 

The  Routine  Instrumental  Exploration  and  Evacuation  of  the  Uterus 
in  the  Treatment  of  Sepsis  after  Labor. — These  terms  are  used  advisedly  instead 
of  that  much  misapplied  expression  "curetment  of  the  puerperal  uterus."  Exper- 
ience teaches  the  necessity  of  this  procedure  in  the  majority  of  septic  cases.  There 
is  usually  a  mass  of  hypertrophied  and  necrotic  decidua  in  a  septic  uterus  the 
removal  of  which  benefits  the  patient.  Xo  one  can  tell  the  condition  of  the  uterine 
cavity  until  it  is  explored.  Consequently  the  following  procedure  is  essential  in 
the  treatment  of  the  majority,  if  not  all,  infected  puerperee:  The  vulva  and 
vagina  are  disinfected;  a  bivalve  speculum  (Collins)  is  inserted  and  widely  dis- 
tended; the  cervix  is  wiped  off  with  pledgets  of  cotton  and  sublimate  solution  and 
an  Emmet's  curet  forceps  is  gently  inserted  into  the  uterine  cavity,  cautiously 
opened  and  closed  in  all  directions;  if  there  is  any  doubt  as  to  the  removal  of 
all  the  necrotic  material,  a  broad  dull  curet  is  held  between  the  thumb  and  fore- 
finger and  with  the  greatest  gentleness  is  passed  lightly  over  the  uterine  walls.  If 
there  is  nothing  in  the  uterus  to  be  removed  there  is  no  result;  if  there  is,  it  is 
discovered  and  removed  at  the  same  time,  without  traumatism,  without  pain,  and 
without  anesthesia.  The  insertion  of  the  whole  hand  in  the  uterus  in  the  early 
puerperium  will  tear  open  wounds  of  the  genital  canal  and  is  usually  so  painful  to  the 
patient  as  to  demand  an  anesthetic.  The  gentle  use  of  instruments  is  painless  and 
is  much  quicker. 

The  reason  that  instrumental  exploration  and  evacuation  of  the  puerperal 
uterus  has  fallen  into  disrepute  is  that  the  average  physician  has  carried  it  out  like 
curetment  of  the  non-puerperal  uterus,  a  procedure  necessarily  often  followed  by 
fatal  general  infection  or  even  by  perforation  of  the  uterus. 

Vaginal  Section  for  Pelvic  Suppuration  or  for  Infection  of  the  Pelvic 
Connective  Tissue. — Whenever  in  the  course  of  puerperal  infection  there  are 
physical  signs  of  an  abscess  in  Douglas'  pouch  and  no  evidence  of  involvement 
of  the  general  peritoneal  cavity,  or  in  case  abdominal  section  is  indicated  but 
the  woman's  condition  is  too  bad  to  admit  of  it,  a  colpotomy  of  the  posterior 
vaginal  vault  and  an  irrigation  of  the  pelvic  canity  with  sterile  water  are  indicated. 
After  cleansing  the  vagina  with  tincture  of  green  soap  and  a  sublimate  douche, 

117 


118  OPERATIVE   TREATMENT   OF    SEPSIS   IN    CHILD-BEARING   PERIOD, 

the  mucous  membrane  of  the  posterior  vaginal  vault  is  incised  with  a  knife,  and 
then,  with  sharp-pointed  scissors  or  the  fingers,  the  opening  into  the  peritoneal 
cavity  is  completed.  Adhesions  are  cautiously  separated  so  as  to  avoid  opening 
the  general  peritoneal  cavity  and  the  pelvic  organs  are  carefully  palpated  to  detect 
isolated  foci  of  suppuration,  w^hich  if  found  are  opened.  The  pelvis  is  irrigated 
through  a  two-way  catheter  with  sterile  water  and  then  packed  quite  firmly  with 
a  strip  of  iodoform  gauze.  The  vagina  is  also  packed.  The  pelvic  packing  is 
removed  in  forty-eight  hours  and  is  replaced  by  a  T-shaped  rubber  drainage-tube, 
through  which  the  pelvic  cavity  is  irrigated  daily  with  sterile  water  for  ten  to  fourteen 
days.  Incisions  in  the  lateral  fornices  and  gauze  drainage  are  of  service  in  suppura- 
tion of  the  parametrium  or  in  accumulations  of  infected  serum  in  it. 

Pryor^  advises  a  routine  examination  of  the  uterine  interior  by  means  of  Doder- 
lein's  method  in  order  to  determine  the  nature  of  the  infection.  After  that  he  washes 
out  the  uterus  with  Thiersch's  solution  and  packs  it  full  of  iodoform  gauze,  10  to 
20  per  cent,  strength.  He  does  not  curet  the  uterus  if  the  streptococcus  has  been 
found.  The  posterior  cul-de-sac  is  then  opened  by  a  broad  incision.  In  all  cases 
a  quantity  of  fluid  escapes,  either  serum,  serolymph,  or  seropus,  or  even  pure  pus. 
In  case  there  is  much  effusion  of  lymph  and  the  organs  are  matted  together,  all  ad- 
hesions are  rapidly  broken  up  by  the  fingers.  The  uterus  is  now  lifted  up  and  the 
posterior  vaginal  wall  depressed.  The  pelvis  is  packed  full  of  iodoform  gauze, 
5  per  cent,  strength.  The  pelvis  is  completely  filled  from  side  to  side,  the  first  piece 
being  placed  well  to  one  side  of  the  pelvis  over  the  iliac  vessels  and  extending  to  the 
pelvic  brim.  When  the  packing  is  complete,  the  iodoform  gauze  is  in  apposition 
with  the  posterior  layers  of  the  broad  ligament  and  the  uterus  and  is  in  contact  with 
all  that  pelvic  portion  of  the  peritoneum  which  overlies  those  lymphatics  and  veins 
which  carry  the  infection.     In  forty-three  cases  he  reports  a  mortality  of  2  per  cent. 

Indications  for  Abdominal  Section  in  the  Treatment  of  Puerperal  Sep- 
sis.— Since  the  first  performance  by  Tait  of  abdominal  section  for  purulent 
peritonitis  there  has  been  an  extremely  important  development,  especially  in  the 
last  decade,  in  the  scope  of  pelvic  and  abdominal  surgery  for  septic  inflamma- 
tion during  the  child-bearing  period. 

Regarded  at  first  as  a  procedure  analogous  to  opening  an  abscess  anywhere  in 
the  body,  the  whole  abdominal  cavity  being  looked  upon  as  an  abscess-cavity  and 
the  abdominal  w^alls  as  its  capsule,  abdominal  section  for  puerperal  sepsis  has 
become  a  generic  term  of  wide  significance,  including  hysterectomy,  salpingo- 
oophorectomy,  evacuation  of  abscesses  in  the  peritoneal  cavity  and  in  the  pelvic 
connective  tissue,  removal  of  gangrenous  or  infected  neoplasms  either  of  or  in  the 
neighborhood  of  the  parturient  tract,  and  exploratory  incisions. 

It  is  more  convenient  to  deal  genericallv  with  the  indications  for  abdominal 
section  in  the  course  of  puerperal  sepsis,  for  the  operation  is  usually  decided  upon 
in  practice  without  reference  to  what  may  be  required  after  the  abdomen  is  opened, 

1  Pryor,  W.  R.:  "  Puerperal  Sepsis,"  Proceedings  of  the  Obstetrical  Society  of  Philadelphia, 
Annals  of  Gyn.  and  Pediat.,  March,  1904,  p.  150. 


ABDOMINAL    SECTION   IN    TREATMENT    OF    PUERPERAL   SEPSIS.  119 

the  surgeon  being  prepared  to  perform  any  of  the  pelvic  or  abdominal  operations 
detailed  above  that  may  be  found  necessary  when  the  abdominal  cavity  is  exposed 
to  view  and  to  touch. 

In  order  to  decide  correctly  the  important  and  anxious  question  for  or  against 
celiotomy  in  the  course  of  puerperal  septic  fever,  the  medical  attendant  must  be 
familiar  with  the  different  forms  of  sepsis  after  labor,  and  should  know  which  of 
them  are  most  and  which  are  least  amenable  to  surgical  treatment.  In  a  general 
way,  it  may  be  stated  that  the  operation  is  demanded  most  frequently  for  localized 
suppurative  peritonitis;  it  may  be  indicated,  and  often  is,  for  diffuse  suppurative 
peritonitis;  for  suppurative  salpingitis  and  ovaritis;  for  suppurative  metritis,  if 
the  inflammation  extends  outward  toward  the  peritoneal  investment  of  the  womb 
or  into  the  connective  tissue  of  the  broad  ligament;  for  abscesses  in  the  pelvic 
connective  tissue ;  for  infected  abdominal  or  pelvic  tumors.  On  the  contrary,  ab- 
dominal section  is  contraindicated  or  is  not  required  in  simple  sapremia;  in  septic 
endometritis  of  all  forms,  necrotic,  pseudo-membranous,  ulcerative,  suppurative; 
in  dissecting  metritis,  sloughing  intrauterine  myomata  (with  occasional  exceptions), 
or  in  suppurative  metritis  with  the  abscess  pointing  into  the  uterine  cavity;  in 
phlebitis,  lymphangitis,  and  in  direct  infection  of  the  blood-current.  One  is  most 
likely  to  perform  an  unnecessary  operation  for  septic  endometritis.  When  symp- 
toms justify  surgical  intervention  in  this  condition,  it  is  always  too  late. 

It  is  extremely  difficult  to  lay  down  correct  rules  for  the  guidance  of  a  physician 
in  a  situation  involving  so  much  responsibility,  and  of  necessity  so  dependent  upon 
many  circumstances,  as  that  seeming  to  require  a  very  serious  surgical  operation  in 
the  midst  of  an  adynamic  fever  with  profound  depression,  rapid  pulse,  high  tem- 
perature— in  short,  with  everything  a  surgeon  least  desires  in  the  face  of  a  major 
operation. 

First  and  foremost,  then,  the  surgeon  should  avoid  the  operative  treatment  of 
puerperal  sepsis  if  possible,  and  should  not  seek  an  excuse  for  surgical  intervention 
merely  in  the  cardinal  symptoms  of  septic  infection — high  temperature,  rapid  pulse, 
and  general  depression.  He  should  demand  some  tangible  evidence  of  those  forms 
of  sepsis  that  are  amenable  to  surgical  treatment.  But  while  reluctant  to  operate 
upon  a  patient  under  the  least  favorable  circumstances,  and  on  his  guard  against 
unnecessary  or  harmful  surgery,  the  surgeon  must  be  prepared,  in  the  event  of  cer- 
tain symptoms  or  complications,  to  operate  with  ihe  least  possible  delay. 

Thus,  on  the  very  first  appearance  of  symptoms  that  justify  the  diagnosis  of 
diffuse  suppurative  peritonitis,  the  abdomen  must  be  opened  without  a  moment's 
more  delay  than  is  necessary  for  an  aseptic  operation.  Even  with  the  utmost  prompt- 
ness the  operation  is  almost  always  too  late,  for  the  inflammation  extends  so  rapidly, 
and  at  first  insidiously,  that  by  the  time  a  diagnosis  is  possible  the  progress  of  the 
disease  cannot  be  stayed.  It  must  be  admitted,  however,  that  an  occasional  suc- 
cess is  possible  by  timely  surgical  interference.^ 

1  Hirst:  "A  Diffuse,  Unlimited,  Suppurative  Peritonitis  in  a  Child-bearing  Woman  Cured  by- 
Abdominal  Section,"  Medical  News,  1894.     A  unique  case  in  my  experience. 


120  OPERATIVE   TREATMENT    OF    SEPSIS    IN    CHILD-BEARING    PERIOD. 

Again,  in  the  presence  of  exudate,  adhesions,  or  unnatural  enlargement  of  any 
pelvic  structure,  suppuration  may  be  suspected  if  the  physical  signs  do  not  improve 
and  if  the  temperature,  pulse,  and  general  condition  indicate  a  continuance  of  sep- 
tic inflammation.  It  is  hardly  necessary  to  state  that  if  pus  forms  it  must  be  reached 
and  evacuated  irrespective  of  its  situation.  Just  how  long  to  wait,  however,  is  a 
question  requiring  experience,  good  judgment,  and  a  special  study  of  each  indi- 
vidual case  for  its  correct  answer. 

Enormous  pelvic  and  abdominal  exudates  may  disappear;  adhesions  may  melt 
away;  enlarged  and  inflamed  tubes,  ovaries,  and  uterus  may  resume  their  proper 
size,  functions,  and  conditions  on  the  subsidence  of  the  inflammation;  but  in  these 
favorable  cases  distinct  signs  of  improvement  manifest  themselves  in  a  few  days, 
and  the  course  of  the  disease  is  comparatively  short.  A  mere  protraction  of  septic 
symptoms  is  in  itself  suspicious,  along  with  local  signs  of  inflammation.  Without 
the  latter,  the  same  general  symptoms,  sometimes  lasting  for  months,  indicate 
phlebitis  and  infection  of  the  blood-current.  In  this  form  of  sepsis  an  operation 
can  do  no  good  and  may  do  the  greatest  harm. 

In  infected  tumors  of  and  near  the  genital  tract  the  indications  for  operation 
should  be  plain  and  the  decision  easy.  The  presence  of  the  tumor  should,  of  course, 
be  known.  On  the  first  sign  of  inflammation  in  it,  or  in  the  event  of  an  elevated 
temperature  for  which  there  is  no  good  explanation,  the  tumor  should  be  removed. 
Early  operations  in  these  cases  have  furnished  the  best  results,  delayed  operations 
the  reverse. 

In  cystic  tumors  the  likelihood  of  twisted  pedicle  should  be  remembered,  and 
in  every  case  of  childbirth  complicated  by  a  new-growth  the  woman  should  be 
watched  with  extraordinary  care  to  detect  the  first  indication  of  infection. 

An  exploratory  abdominal  incision  should  be  made,  as  a  rule,  only  when  it  is 
desirable  to  determine  whether  a  pelvic  mass,  presumably  containing  pus,  is  situated 
within  or  without  the  peritoneal  cavity,  and  whether  the  abscess  should  be  evacuated 
through  the  abdominal  cavity  or  extraperitoneally.  In  the  early  period  of  experi- 
mentation with  abdominal  section  for  puerperal  sepsis  exploratory  incisions  were 
made  in  obscure  cases  without  any  local  symptoms  of  inflammation  in  the  pelvis  or 
the  abdomen.  None  of  these  operations  yielded  information  of  value,  nor  did  they 
benefit  the  patient.  Consequently,  it  is  a  safe  rule  not  to  open  the  abdomen  of  a 
puerpera  for  sepsis  unless  there  are  physical  signs  of  inflammation  of  the  abdomen 
or  the  pelvis. 

This  is  not  the  place  to  discuss  the  symptoms  of  diffuse  suppurative  peritonitis, 
but  one  fact  should  be  insisted  upon  from  the  operator's  point  of  view.  It  is  usu- 
ally supposed  that  true  diffuse  suppurative  peritonitis  appears  early  after  delivery; 
it  may,  however,  develop  at  any  time,  as  late  as  four  weeks  after  confinement. 
The  technic  of  the  operation  is  simple:  a  small  incision  is  made  in  the  median  line 
and  the  finger  is  rapidly  swept  about  the  pelvis  and  abdomen  to  determine  the 
condition  of  the  organs;  then  the  irrigating  tube  is  passed  into  the  cavity  at  the 
lowest  angle  of  the  wound,  and  is  swept  about  in  all  directions,  while  the  return- 


ABDOMINAL    SECTION   IN   TREATMENT    OF   PUERPERAL   SEPSIS.  121 

flow  is  provided  for  by  two  fingers  of  the  left  hand  distending  the  sides  of  the  wound, 
which  by  the  fingers  and  the  irrigating  tube  is  kept  gaping  as  though  by  a  trivalve 
speculum.  The  irrigation  tube  is  then  pushed  as  far  as  possible,  first  into  one 
flank  and  then  into  the  other,  and  the  tip  is  cut  down  upon  through  the  lateral 
abdominal  wall.  The  posterior  vaginal  vault  is  then  punctured  from  above.  Gauze 
and  glass-tube  drainage  into  the  pouch  of  Douglas,  a  strip  of  gauze  through  the 
puncture  of  the  posterior  vaginal  vault,  and  a  gauze  drain  in  the  flanks  are  provided 
for,  the  wounds  are  left  open,  or,  at  most,  drawn  together  by  a  stitch  or  two.  Rap- 
idity of  operation  and  the  smallest  quantity  of  an  anesthetic  are  essential  to  success. 
The  gauze  drains  are  withdrawn  gradually,  beginning  on  the  fourth  day. 

Trendelenburg,^  observing  that  in  forty-three  autopsies  on  women  dying  of 
puerperal  sepsis  twenty-one  had  pyemic  thrombosis,  advised  ligation  and  excision 
of  the  pelvic  veins  in  the  treatment  of  this  condition.  He  reported  one  successful 
case. 

Opitz,^  after  an  extensive  review  of  Trendelenburg's  plan  and  the  report  of  a 
number  of  cases,  says  that  the  ligation  and  excision  of  diseased  veins  with  or  without 
total  extirpation  of  the  uterus  is  at  best  successful  only  in  exceptional  cases,  and  the 
indications  for  it  are  almost  impossible  to  determine.  He  believes  that  non-oper- 
ative, general  and  supportive  treatment  is  better. 

This  proposition  has  been  sufSciently  tried  in  practice  to  warrant  an  opinion 
that  the  mortality  of  surgical  intervention  in  these  cases  is  greater  than  that  of 
palliative  treatment,  and  that  the  operation  is  not  to  be  recommended. 

Following  these  general  statements  in  regard  to  abdominal  section  for  puerperal 
sepsis,  it  is  more  convenient  to  describe  in  detail  the  different  kinds  of  operations 
required  for  the  various  forms  of  intra-abdominal  septic  inflammations. 

Abdominal  Section  for  Intraperitoneal  Abscesses  and  Diffuse  Suppura- 
tive Peritonitis. — The  situation  and  the  extent  of  localized  suppuration  within 
the  abdominal  cavity  vary  greatly.  A  quarter  of  the  abdominal  cavity  may  be 
filled  with  pus,  the  huge  abscess-cavity  being  thoroughly  walled  off  by  dense  exudate 
from  the  rest  of  the  abdominal  cavity.  A  smaller  accumulation  of  pus  about  the 
orifice  of  the  tube  is  not  uncommon.  In  some  cases  two  or  three  abscesses  the 
size  of  an  orange  may  be  found  between  coils  of  intestine  quite  far  removed  from 
one  another,  and  without  apparent  connection  with  the  genital  tract.  In  three  of 
the  writer's  cases  abscesses  were  found  between  the  fundus  uteri  and  the  adjoining 
structures — the  abdominal  wall  near  the  umbilicus  in  one,  the  caput  coli  in  the 
second,  and  the  sigmoid  flexure  in  the  third.  In  these  cases  infection  had  traveled 
through  a  sharply  defined  area  of  uterine  wall  and  had  appeared  in  the  same  limits 
on  its  peritoneal  investment.  Exudate  and  adhesions  immediately  walled  off  the 
infected  area,  with  the  result  of  an  encapsulated  abscess  between  the  uterine  wall 
and  the  structure  nearest  to  it  at  the  time  of  inflammation.     The  treatment  of  these 

^Trendelenburg,  F.:  "  Ueber  die  chirurgische  Behandlung  der  puerperalen  Pyiimie,"  Miinch. 
med.  Wochenschr.,  April  1,  1902,  No.  13,  pp.  5-13. 

^Opitz,  E.:  "  Ueber  Heilungsaussichten  und  Behandlung  der  puerperalen  Pyiimie,"  Deutsch. 
med.  Wochenschr.,  1904,  No.  25,  p.  910;  No.  26,  p.  953;  No.  27,  p.  986. 


122  OPERATIVE   TREATMENT    OF   SEPSIS   IN    CHILD-BEARING    PERIOD. 

abscesses  is  their  evacuation,  the  cleansing  of  the  cavity,  and  drainage.  The 
cleansing  may  be  effected  by  flushing  with  hot  sterilized  water,  if  the  rest  of  the 
abdominal  cavity  can  be  guarded  from  contamination.  In  many  cases  it  is  better 
to  avoid  irrigation  and  to  thoroughly  dry  the  cavities  with  gauze.  For  drainage, 
as  a  rule,  sterile  gauze  with  a  glass  or  rubber  tube  is  usually  best.  In  certain  cases 
of  abscesses  near  the  abdominal  wall,  a  rubber  tube  answers  better  than  the  gauze, 
and  in  deep-seated  abscesses  on  the  base  and  the  back  of  the  broad  ligaments  vagi- 
nal drainage  by  means  of  gauze  or  rubber  tube  is  much  to  be  preferred.  If  the 
work  during  the  operation  is  well  done,  there  may  be  little  or  no  subsequent  dis- 
charge, and  douching  of  the  abscess-cavities  during  convalescence  is  uncalled  for. 
Occasionally,  however,  if  the  abscess-cavity  is  very  large  and  well  isolated,  daily 
douching  with  sterile  hot  water  is  an  advantage.  In  diffuse  suppurative  peritonitis 
the  remote  chance  of  success  depends  greatly  upon  the  earliest  possible  operation 
and  the  most  thorough  drainage,  though  there  are  many  virulent  cases  in  which 
nothing  could  check  the  spread  of  the  inflammation  and  the  deadly  effect  of  septic 
intoxication. 

Salpingo-oophorectomy  for  Puerperal  Sepsis. — It  sliould  be  remembered 
that  tubal  or  ovarian  abscesses  in  the  puerperium  are  preferably  treated  by  vaginal 
incision  and  drainage.  When  from  their  position  this  is  not  feasible,  salpingo-oophor- 
ectomy may  be  required.  An  acute  pyosalpinx  in  the  puerperium  is  very  rare.  It 
is  uncommon  for  the  acute  septic  infection  after  labor  to  travel  by  the  tubes  alone. 
Infection  usually  occurs  in  the  uterine  muscles,  the  veins,  the  lymphatics,  or  the 
connective  tissue  of  the  pelvis.  When  the  tract  of  the  septic  inflammation  is  con- 
fined to  the  mucous  membrane  of  the  genital  tract,  the  pelvic  peritoneum,  in  a  case 
serious  enough  to  demand  operation  during  puerperal  convalescence,  becomes 
infected  and  inflamed ;  suppuration  quickly  follows,  so  that  the  operation  is  usually 
performed  for  an  intraperitoneal  pelvic  abscess.  The  tube  may  be  found  some- 
what swollen,  dark  red  in  color,  containing  a  few  drops  of  pus,  with  flakes  of 
purulent  lymph  on  its  external  surface,  and  its  removal  is  required;  but  the  pyo- 
salpinx is  a  subordinate  feature  in  the  pelvic  inflammation.  It  is  the  more  subacute 
case,  not  usually  requiring  operation  in  the  conventional  period  of  the  puerperium, 
that  results  later  in  a  typical  uncomplicated  pus-tube. 

Ovarian  abscess  is  much  more  common  than  pyosalpinx.  The  infection  may 
travel  to  the  ovary,  both  by  way  of  the  tube  and  by  the  connective  tissue,  the 
blood-vessels,  or  the  lymphatics  of  the  broad  ligament.  In  the  latter  case  the  whole 
ovary  may  be  infiltrated  with  a  thin  sero-pus  of  a  particularly  virulent  character, 
and,  unfortunately,  in  excising  the  ovary  the  exposure  of  the  infected  pelvic  con- 
nective tissue  in  the  stump  may  lead  to  infection  of  the  peritoneal  cavity  and  to  a 
diffuse  suppurative  peritonitis. 

The  commonest  indication  for  salpingo-oophorectomy  is  furnished  by  a  pus- 
tube  antedating  conception.  The  strain  of  labor  excites  a  fresh  outbreak  of  inflam- 
mation, which  leads  to  its  spread,  and  the  persistence  of  septic  symptoms  with  the 
physical  signs  of  pelvic  inflammation  justifies  operative  interference.     Sometimes 


HYSTERECTOMY   FOR   PUERPERAL   SEPSIS.  123 

the  operation  must  be  performed  on  a  presumptive  diagnosis  of  old  pus-tubes, 
based  mainly  upon  the  patient's  history  and  the  existence  of  serious  septic  symp- 
toms, with  tenderness  on  abdominal  palpation  over  the  region  of  the  tube  and  ovary. 
The  uterus  may  be  much  too  high  in  the  abdominal  cavity  for  a  satisfactory  pelvic 
examination  of  the  uterine  appendages. 

There  is  often  nothing  peculiar  in  the  technic  of  these  operations.  They  differ, 
usually,  in  no  respect  from  similar  operations  upon  non-puerperal  patients.  The 
question  of  removing  the  uterus  along  with  the  tubes  arises,  however,  rather  more 
frequently  than  in  the  non-puerperal  woman,  on  account  of  the  infection  of  the 
endometrium  or  of  persistent  metrorrhagia.  But  in  associated  suppurative  sal- 
pingitis, ovaritis,  and  infection  of  the  connective  tissue  of  the  broad  ligament,  there 
is  a  modification  of  the  ordinary  technic,  which  is  of  vital  importance.  The  tubes 
and  the  ovaries  should  be  excised,  the  blood-vessels  of  the  broad  ligaments  tied 
separately;  the  cut  edges  of  the  broad  ligaments  should  be  allowed  to  gape;  the 
whole  pelvic  cavity  should  be  filled  with  gauze  and  drained  by  a  glass  tube  placed 
just  posterior  to  the  uterus.  The  dressings,  sterile  gauze  and  cotton,  cover  the 
tube  and  wound  completely.  They  are  not  disturbed  for  twenty-four  hours,  when 
the  tube  is  sucked  out  by  a  syringe.  Twenty-four  hours  later  the  gauze  is  removed, 
the  tube  again  sucked  out  and  removed,  after  the  rubber  drainage-tube  is  slipped 
within  it,  to  take  its  place.  Through  the  rubber  tube  the  pelvis  is  washed  out  daily 
with  sterile  water.  Apparently  most  desperate  cases  may  be  saved  by  this  technic. 
Hysterectomy  for  Puerperal  Sepsis. — Osterloh^  says  that  Schultze  was 
the  first  to  advise  hysterectomy  in  the  treatment  of  puerperal  sepsis.  The  indica- 
tions for  it  as  given  by  Schultze^  are:  There  must  be  an  active  source  of  infection 
in  the  uterus  which  cannot  be  treated  by  way  of  the  genital  tract.  (2)  There  must 
be  no  other  imminent  source  of  infection  outside  of  the  uterus.  (3)  There  must 
be  no  probability  of  an  extension  of  the  infection  outside  of  the  uterus,  as,  for  ex- 
ample, in  more  or  less  removed  thrombi  or  emboli. 

This  plan  at  first  received  very  little  attention,  but  within  recent  years  has  been 
very  widely  discussed.  There  seems  to  be  more  or  less  a  consensus  of  opinion  that 
hysterectomy  alone  should  only  be  performed  in  case  the  original  indications  of 
Schultze  obtain.  Thus  LeopokP  believes  that  hysterectomy  is  indicated  in  puer- 
peral infection  only  when  all  the  symptoms  indicate  that  the  uterus  alone  is  the 
situation  and  the  actual  source  of  the  infection. 

Fehling*  says  that  hysterectomy  can  rationally  be  recommended  only  if  the  in- 
toxication or  the  infection  is  entirely  limited  to  the  uterus.  He  reports  sixty-one 
cases  with  a  mortality  of  55.7  per  cent. 

^Osterloh:  "  Beitrag  zur  Behandlung  der  puerperalen  Sepsis,"  Miinch.  med.  Wochenschr., 
1902,  No.  21,  p.  894. 

2 Schultze,  B.  S.:  "Amputation  des  corpus  uteri  mittels  Laparotomie  wegen  Retention  der 
Placenta  und  puerperaler  Sepsis,"  Centralbl.  fiir  Gyniik.,  1886,  No.  47,  p.  765. 

^Leopold:  "Die  Hysterectomie  in  der  Behandlung  der  puerperalen  Infection,"  Centralbl. 
fur  Gynak.,  1902,  No.  44,  p.  1162. 

^Fehling,  H.:  "Hysterectomie  in  der  Behandlung  der  puerperalen  Infection,"  Centralbl. 
fiir  Gynak.,  1902,  No.  44,  p.  1162. 


124  OPERATIVE   TREATMENT    OF    SEPSIS    IN    CHILD-BEARING    PERIOD. 

Treub^  reports  seven  hundred  and  twenty-four  cases  of  puerperal  infection 
treated  expectantly  with  thirty-four  deaths.  In  only  six  of  the  fatal  cases  was  the 
disease  localized  to  the  uterus,  and  the  autopsies  in  two  of  these  cases  showed  that 
hysterectomy  would  have  been  entirely  useless. 

Treub  mentions  thirty-six  cases  of  total  extirpations,  of  which  fifteen  were  saved. 
He  contrasts  this  result  with  that  obtained  through  conservative  treatment.  More 
Hves  are  lost  than  saved  by  a  radical  operation,  to  say  nothing  of  the  mutilation  of 
the  pelvic  organs  if  the  woman  survives. 

Bumm^  says  that  hysterectomy  will  be  successful  in  cases  complicated  by  wounds 
of  the  uterus  received  during  the  induction  of  abortion  or  operative  manipulations 
during  labor.  It  will  also  be  of  service  in  case  of  gangrene  of  the  uterus  such  as 
might  be  caused  by  the  necrosis  of  a  myoma  or  the  retention  within  the  uterus  of 
fetal  parts  or  large  pieces  of  placenta. 

V.  WinckeP  says  that  to  extirpate  the  uterus  in  every  case  of  diffuse  suppurative 
peritonitis  simply  because  it  is  the  starting-point  of  the  trouble,  without  waiting  to 
see  if  the  patient  is  not  materially  improved  by  the  removal  of  the  exudate,  is  quite 
irrational,  because  by  doing  hysterectomy  all  of  the  infectious  material  is  not  by 
any  means  removed. 

Norris*  quotes  Valere  Cocq  as  saying  that  hysterectomy  is  indicated  when  there 
is  a  grave  toxemia  and  the  uterus  has  in  all  probability  become  the  chief  entrance 
of  the  septic  material,  and,  other  means  of  treatment  having  failed,  the  patient  is 
still  strong  enough  to  stand  operation.  These  conditions  are  found  in  certain  cases 
where  the  placenta  has  been  retained  and  is  undergoing  decomposition  and  cannot 
be  removed  by  the  curet.  In  cases  of  suppurative  metritis  this  is  also  true.  In 
cases  showing  extensive  involvements  of  the  parametrium  and  adnexa,  though  they 
are  often  treated  with  ice  and  opium  in  the  hope  of  avoiding  an  operation,  the  radical 
operation  sooner  or  later  is  found  to  be  necessary  to  save  the  life  of  the  patient. 

As  may  be  seen,  the  removal  of  all  the  pelvic  organs  and  structures  that  can  be 
removed  by  hysterectomy  is  a  subject  which  has  created  wide-spread  discussion. 
Every  physician  who  has  seen  many  cases  of  puerperal  infection  during  operations 
or  post-mortem  is  aware  that  there  are  some  in  which  the  mere  removal  of  infected 
tubes  and  ovaries,  vaginal  section  and  drainage,  or  the  evacuation  of  pelvic  abscesses 
through  the  abdomen  cannot  be  expected  to  save  the  patient. 

There  would  be  left  behind  areas  of  infected  and  infiltrated  broad  ligaments 
that  would  communicate  infection  to  the  peritoneal  cavity,  there  would  remain 
foci  of  suppuration  or  infection  in  the  uterine  body  that  must  surely  spread  to  the 
peritoneum  or  must  result  in  septic  metastases,  and  the  streptococcic  invasion  of 

^  Treub,  H.:  "  Hysterectomie  in  der  Behandlung  der  puerperalen  Infection,"  Centralbl.  fiir 
Gynak.,  1902,  No.  44,  p.  1162. 

^Bumm,  E.:  "  Ueber  die  chirurgische  Behandlung  des  Kindbettfiebers,"  Referat  in  dem 
Centralbl.  fur  Gynak.,  No.  8,  1902,  p.  219. 

'v.  Winckel,  F.:  "Ueber  die  Koliotomie  bei  der  diffusen  eitrigen  puerperalen  Peritonitis," 
"Therapeut.  Monatshefte,"  1895,  S.  178. 

*  Norris,  R.  C:  "  Progressive  Medicine,"  Sept.,  1904,  p.  255. 


HYSTERECTOMY    FOR   PUERPERAL   SEPSIS. 


125 


the  myometrium  not  infrequently  is  followed  by  necrosis  of  the  uterus.  The  only 
hope  for  the  patient  in  such  cases  lies  in  the  entire  removal  of  all  infected  areas, 
leaving  behind  in  the  pelvis  a  healthy,  non-infected  stump.  To  effect  this  result 
the  excision  of  the  uterus,  the  broad  ligaments,  the  tubes,  and  the  ovaries  is  required. 
In  addition  to  these  cases,  there  are  others  in  which,  if  the  tubes  and  ovaries  must  be 
excised,  the  uterus  might  be  removed  with  advantage,  on  account  of  an  infected 
endometrium  or  of  persistent 
metrorrhagia.  Fig.  416  is  an 
example  of  such  a  case.  The 
young  woman  from  whom  the 
specimen  was  removed  had  a 
double  pyosalpinx  following  a 
criminal  abortion.  For  seven 
weeks  she  had  been  bleeding 
persistently,  and  at  intervals 
had  a  foul-smelling  discharge. 
Although    the    body    of    the 

uterus  was  healthy  and  the  endometrium  alone  was  inflamed  and  infected,  it  was 
obviously  wiser  to  remove  at  once  all  sources  of  the  trouble  rather  than  to  excise 
the  tubes  and  ovaries  and  then  to  treat  separately  at  some  trouble  and  risk  an  organ 
that  had  become  entirely  superfluous.  There  may  also  be  such  wide-spread  suppura- 
tion and  disintegration  of  the  broad  ligaments,  with  tubal  inflammation,  that  it  is 
easier  to  remove  all  the  infected  area,  and  to  control  hemorrhage,  by  a  hysterectomy. 
Fig.  417  represents  such  a  case.     A  pyosalpinx  antedated  conception.     Labor 


Fig.  416. — Hysterectomy  for  Purulent  Salpingitis 
(Author's  Case). 


Fig.  417. — Suppurative  Cellulitis  of  Broad  Ligament;    Hysterectomy  (Author's  Case). 


excited  fresh  inflammation.  The  infection  spread  through  the  tube  downward 
through  the  connective  tissue  of  the  broad  ligament,  resulting  in  its  partial  destruc- 
tion, in  a  thick  infiltration  at  its  base,  and  in  an  abscess  between  its  layers,  closely 
hugging  the  whole  of  one  side  of  the  uterine  body.  It  was  obviously  impossible 
to  remove  the  infected  area  without  removing  the  womb  as  well.  The  operation, 
though  undertaken  under  the  most  discouraging  circumstances,  was  successful. 


126 


OPERATIVE   TREATMENT    OF    SEPSIS    IN    CHILD-BEARING    PERIOD. 


There  can  be  no  doubt  as  to  the  necessity  of  hysterectomy  in  the  cases  represented 
in  Figs.  418  and  419.  There  were  abscesses  in  the  uterine  wall,  directly  under  the 
peritoneal  envelop,  about  to  break  into  the  peritoneal  cavity;  one,  indeed,  did 
rupture  during  the  operation.  There  was  a  septic  ulceration  at  the  placental  sac, 
in  one  case  so  nearly  perforating  the  uterine  wall  that  by  a  light  touch  during  the 

operation  the  forefinger  passed 
into  the  uterine  cavity.  There 
was  also  a  pyosalpinx,  in  these 
cases,  which,  judging  by  the 
history,  antedated  or  was  coin- 
cident with  impregnation. 
The  operations  saved  the  pa- 
tients. In  another  successful 
hysterectomy  for  puerperal 
sepsis,  the  author  found  the 
womb  completely  ruptured  at 
the  fundus  from  tube  to  tube. 
The  diagnosis  of  the  injury  had  not  been  made.  The  operation  was  under- 
taken some  weeks  after  labor,  for  what  was  thought  to  be  an  intraperitoneal 
abscess.  Areas  of  suppuration  were  discovered,  but  the  greater  bulk  of  the  in- 
flammatory mass  was  exudate  which  had  shut  off  the  general  peritoneal  cavity 
from  infection  through  the  gaping  uterine  wound.  In  cases  of  streptococcic  infec- 
tion the  whole  uterus  may  be  found  so  necrotic  that  its  consistence  is  that  of  cheese. 


Fig.  418. 


-Suppurative  and  Ulcerative  Metritis,  Salpingitis; 
Hysterectomy  (Author's  Case.) 


Fig.  419. — Suppurating'  Metritis. 
a,  a,  a.  Abscess  cavities.     Hysterectomy  two  weeks  after  labor.     Recovery. 


No  ligature  holds  in  it  and  the  uterine  wall  may  be  pinched  through  anywhere  by 
the  thumb  and  forefinger.  One  might  as  well  expect  a  woman  to  live  with  a  gan- 
grenous coil  of  intestine  in  her  abdomen  as  with  such  a  gangrenous  and  necrotic 
uterus.  She  can  only  be  saved,  if  at  all,  by  a  hysterectomy.  It  may  also  be  nec- 
essary to  remove  the  uterus  in  the  puerperium  to  get  rid  of  an  infected  fibromyoma, 


HYSTERECTOMY   FOR   PUERPERAL   SEPSIS.  127 

as  illustrated  in  Fig.  420.  This  uterus  was  removed  on  the  fourth  day  of  the  puer- 
perium,  the  patient's  temperature  having  been  104°  F.  and  the  pulse  140.  Strep- 
tococci were  found  in  the  interior  of  the  tumor  and  there  was  general  svstemic 
infection,  with  phlebitis  and  septic  pneumonia,  but  the  woman  recovered. 

Indications  for  the  Operation. — The  indications  for  hysterectomy  during  puer- 
peral sepsis  are  furnished  by  the  condition  of  the  pelvic  organs  when  they  are  exposed 
to  sight  and  touch  after  the  abdomen  is  opened.  The  six  conditions  described 
above  are  the  types  calling  for  hysterectomy.  It  is  not  often  possible  to  determine 
upon  hysterectomy  before  the  abdomen  is  opened,  but  it  should  be  remembered 
that  in  any  abdominal  section  for  puerperal  sepsis  hysterectomy  may  be  necessary. 
The  surgeon,  therefore,  should  be  prepared  for  hysterectomy  in  every  abdominal 
section  for  puerperal  sepsis,  but  should  rest  content  with  the  least  radical  measure 
that  promises  his  patient  safety.     It  may  be  sufficient  to  excise  the  cornua  or  the 


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■\ 

^ 

L  '^  '^S 

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IgSHn 

tI^H| 

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^H 

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Fig.  420. — Submucous  Fibroma  Removed  by  Hysterectomy  in  Early  Puerperium  (Author's  Case). 

fundus.  The  operation  that  is  quickest  done  and  shocks  the  patient  least  is  most 
successful,  provided,  of  course,  that  it  is  adequate. 

Technic  of  the  Operation. — There  are  two  points  in  which  the  technic  of  hysterec- 
tomy for  puerperal  sepsis  may  differ  from  the  technic  of  the  operation  performed 
for  other  conditions.  One  of  these  points  is  the  necessity  often  of  doing  pan- 
hysterectomy; the  other  is  the  neces.sity  often  of  tying  the  ligatures  in  a  broad  liga- 
ment much  thickened  bv  inflammatorv  exudate  or  bv  ligatino;  the  blood-vessels 
separately  so  as  not  to  include  an  infected  mass  in  the  ligature. 

The  author's  preference  is  for  amputation  of  the  uterus,  leaving  as  little  cervix 
as  possible,  unless  an  examination  of  the  cervix  by  a  speculum  shows  septic  ulcera- 
tion or  exudate  upon  it  or  in  its  canal.  The  reasons  for  this  preference  for  ampu- 
tation of  the  womb  over  pan-hysterectomy  are  that  the  former  can  be  done  more 
quickly,  there  is  not  the  same  anxiety  about  the  cleanliness  of  the  vagina,  the  suture 


128  OPEEATIVE   TEEATMENT    OF    SEPSIS   IN    CHILD-BEARING   PERIOD. 

material  is  more  certainly  guarded  from  infection  afterward,  and  there  is  less  danger 
of  cutting  or  ligating  the  ureters. 

The  thickened  broad  ligaments  are  often  a  source  of  serious  embarrassment 
in  placing  and  tying  the  ligatures  around  the  uterine  arteries.  There  is  difficulty  to 
contend  with  in  the  majority  of  operations.  In  some  cases  the  inflammatory  exudate 
within  and  below  the  ligature  breaks  down  into  pus,  but  an  incision  in  the  posterior 
vaginal  vault  evacuates  the  pus  and  usually  secures  an  immediate  disappearance 
of  somewhat  alarming  symptoms.  It  may  be  necessary  to  do  this  as  late  as  four 
weeks  after  the  hysterectomy.  Vaginal  hysterectomy  is  usually  unsuitable  for 
cases  of  puerperal  sepsis  on  account  of  the  danger  of  clamping  or  ligating  large 
masses  of  infiltrated  and  infected  broad  ligament,  on  account  of  the  stiffened  and 
adherent  broad  ligaments,  which  make  downward  traction  on  the  uterus  difficult 
or  impossible,  and  because  it  is  impracticable  in  a  vaginal  operation  to  explore 
the  pelvis  and  abdomen  for  foci  of  infection  at  some  distance  perhaps  from  the  pelvic 
organs. 

Exploratory  Abdominal  Section  for  Puerperal  Sepsis. — An  exploratory 
incision  should  be  made  only  in  cases  of  suspected  extraperitoneal  pelvic  abscess, 
to  confirm  one's  suspicion,  to  be  certain  that  none  of  the  pelvic  organs,  especially 
the  tubes,  are  diseased,  and  to  determine  the  best  situation  for  the  incision  that 
shall  evacuate  the  abscess-cavity  without  contaminating  the  peritoneal  cavity. 
This  rule  of  practice  would  exclude  exploratory  abdominal  section  in  cases  with  no 
physical  signs  of  pelvic  inflammation,  but  in  which  there  is  evident  septic  infection 
of  a  nature  difficult  to  determine.  There  are  possible  exceptions  to  the  rule,  how- 
ever, as  in  cases  of  suspected  pyosalpinx  without  physical  signs,  owing  to  the  high 
position  of  the  recently  emptied  womb  and  of  its  appendages. 

A  typical  case  requiring  exploratory  abdominal  section  occurred  in  the  practice 
of  the  author  in  a  woman  who  had  miscarried  some  weeks  before  she  came  under 
observation.  She  had  lost  over  thirty  pounds  in  weight,  was  bedridden,  had  night- 
sweats,  high  fever,  profound  prostration,  and  exacerbations  of  pain  in  the  pelvis. 
On  examination  the  usual  symptoms  of  extraperitoneal  pelvic  exudate  and  suppu- 
ration were  found  on  the  right  side.  "When  the  abdomen  was  opened,  it  was 
found  that  all  the  pelvic  organs  and  the  pelvic  peritoneum  were  perfectly  healthy. 
There  was  a  large  collection  of  pus  between  the  layers  of  the  right  broad  ligament, 
giving  to  this  structure  a  dome-shape.  The  tube  and  ovary  running  over  the  top 
of  the  distended  broad  ligament  were  perfectly  healthy  and  without  a  trace  of  adhe- 
sion or  inflammation  of  any  kind.  With  the  abdomen  opened  it  was  easy  to  locate 
the  level  of  the  anterior  duplication  of  the  peritoneum.  A  mark  was  made 
on  the  skin  an  inch  below  this  point,  the  abdominal  wound  was  closed,  an 
incision  was  made  in  the  groin,  and  the  pus  washed  out  by  douching.  Sinuous 
tracts  of  suppuration  were  found  by  the  finger  running  up  the  psoas  muscle  and 
down  into  the  floor  of  the  pelvis.  Two  drainage-tubes  were  inserted,  one  upward 
into  the  psoas  muscle,  the  other  downward  into  the  pelvis.  In  the  course  of  this 
woman's  convalescence  it  was  found  advisable  to  make  a  counteropening  in  the 


EXPLORATORY    ABDOMINAL    SECTION    FOR   PUERPERAL   SEPSIS.  129 

right  lateral  fornix  of  the  vagina,  and  to  pass  a  drainage-tube  through  from  the 
opening  in  the  groin  to  the  vagina.  In  this  way  perfect  drainage  was  estabhshed 
and  the  patient  made  a  good  recovery. 

Cases  of  true  extraperitoneal  pelvic  abscesses  due  to  puerperal  infection,  and 
without  intraperitoneal  inflammation,  are  rare. 

For  a  full  discussion  of  this  see  Chapter  IV,  page  298,  Vol.  I.  In  two  of 
my  cases  the  suppuration  was  so  evidently  extraperitoneal  that  an  abdominal 
section  was  dispensed  with.  An  incision  was  made  in  the  flank  above  the 
crest  of  the  ilium  and  another  in  the  groin  above  Poupart's  ligament.  A  pint  or 
more  of  pus  was  evacuated.  In  one  case  an  abdominal  incision  w^as  made  for  what 
was  thought  to  be  an  intraperitoneal  abscess.  Before  the  incision  was  completed 
pus  welled  out  of  the  uterovesical  connective  tissue.  A  large  extraperitoneal 
abscess  w^as  found  between  the  uterus  and  bladder.  It  was  counterdrained  through 
the  anterior  vaginal  vault.  Another  case  exactly  similar  was  deliberately  opened 
by  an  incision  above  the  symphysis  and  below  the  anterior  reduplication  of  the 
peritoneum.     All  these  cases  of  extraperitoneal  suppuration  recovered. 


VOL.  II — 9 


CHAPTER  XXX. 

EXTRAUTERINE    PREGNANCY. 
By  J.  Whitridge  Williams,  M.D. 

In  extrauterine  pregnancy  the  fertilized  ovum  is  arrested  and  undergoes  more 
or  less  complete  development  at  some  point  between  the  follicle  in  which  it  origi- 
nated and  the  uterus.  The  term  "ectopic  gestation,"  which  is  sometimes  used 
synonymously  with  it,  has  a  somewhat  broader  meaning,  and  includes  not  only  the 
usual  varieties  of  extrauterine  pregnancy,  but  also  the  cases  in  which  the  ovum  is 
implanted  in  the  viterus  outside  of  its  normal  cavity. 

This  article  is  limited  to  the  consideration  of  the  typical  forms  of  extrauterine 
gestation,  and  those  who  are  interested  in  pregnancy  in  abnormal  uteri  are  referred 
to  the  exhaustive  monograph  of  Kehrer,  and  to  the  section  by  Werth  in  Winckel's 
"Handbuch  der  Geburtshiilfe." 

I  shall  not  attempt  in  this  place  to  trace  the  history  of  the  affection,  but  refer 
those  who  are  interested  in  it  to  the  monographs  of  Campbell,  Hecker,  Parry,  Tait, 
Webster,  and  Werth,  in  which  it  is  treated  in  detail. 

Frequency. — Up  to  1883,  when  Tait  first  operated  for  a  ruptured  tubal  preg- 
nancy, the  condition  was  important  chiefly  from  a  pathologic  point  of  view,  but 
since  then  it  has  attained  a  markedly  practical  interest.  This  is  manifested  by  the 
constantly  increasing  literature  upon  the  subject.  Henning,  in  1876,  stated  that 
extrauterine  pregnancy  was  so  rare  an  affection  that  even  the  directors  of  large 
obstetric  institutions  might  never  see  a  case,  and  Parry  in  the  same  year  was 
able  to  collect  only  500  cases  from  the  entire  literature ;  while  at  the  present  time 
such  a  task  would  prove  practically  impossible. 

The  increase  in  the  frequency  of  the  affection  is  likewise  borne  out  by  the 
experience  of  individual  operators.  Thus,  Wormser  stated  that  40  cases  were 
observed  in  the  Berne  clinic  during  the  five  years  ending  with  1898,  as  compared 
with  14  cases  in  the  fourteen  preceding  years;  and  Kiistner  saw  105  cases  in 
Breslau  in  the  five  years  ending  with  1899,  but  only  9  during  his  entire  experience 
in  Dorpat.  A  corresponding  increase  has  been  noted  in  nearly  all  large  clinics, 
and  Noble  states  that  from  3  to  4  per  cent,  of  all  his  laparotomies  are  performed 
upon  extrauterine  pregnancy  cases.  Indeed,  Ahlfeld  seems  to  be  the  only  promi- 
nent gynecologist  who  has  not  had  a  similar  experience,  as  he  stated  in  1898  that 
he  had  seen  but  two  cases  during  sixteen  years'  activity  at  Marburg  and  Giessen. 

This  increased  frequency  is,  however,  to  some  extent  more  apparent  than  real, 
and  is  due  partly  to  greater  proficiency  in  diagnosis  and  partly  to  the  fact  that 
the  great  frequency  with  which  the  abdomen  is  now  opened  affords  abundant  oppor- 

130 


CONDITIONS    INTERFERING    WITH   PASSAGE    OF   OVUM.  J.31 

tunity  for  the  recognition  of  many  conditions  which  previously  escaped  discovery. 
At  the  same  time  it  seems  probable  that  there  has  been  an  actual  increase  in  its 
incidence,  as  a  result  of  the  greater  prevalence  of  gonorrhea  and  the  physical 
degeneration  of  the  poor  in  large  cities. 

ETIOLOGY. 

Unfortunately  concise  and  definite  statements  cannot  be  made  concern- 
ing the  etiology  of  the  condition,  but  instead  a  large  number  of  explanations 
of  greater  or  less  plausibility  have  been  advanced,  which  may  be  divided  into 
two  groups  for  more  convenient  consideration:  (1)  Conditions  which  interfere 
mechanically  with  the  downward  passage  of  the  ovum.  (2)  Physical  and  develop- 
mental conditions  which  favor  decidual  formation  in  the  tubes. 


CONDITIONS  WHICH  INTERFERE  MECHANICALLY  WITH  THE  DOWNWARD  PAS- 
SAGE OF  THE  OVUM. 

Peritoneal  Adhesions. — One  of  the  earliest  explanations  for  the  causation  of 
extrauterine  pregnancy  was  sought  in  peritoneal  adhesions,  which  bound  down  and 
constricted  the  tubal  lumen.  According  to  Hennig,  Fritze  in  1779  was  the  first  to 
direct  attention  to  this  condition,  but  the  names  of  Virchow,  Hecker,  and  Roki- 
tansky  are  usually  associated  with  it.  These  authors  believed  that  the  adhesions 
cause  the  arrest  of  the  ovum  by  compressing  the  lumen  of  the  tube,  or  by  inter- 
fering with  its  peristalsis — a  view  which  has  still  some  adherents,  and  is  occasionally 
verified  at  operation  or  autopsy. 

Tubal  Polypi. — A  considerable  number  of  observers,  among  whom  may  be 
mentioned  Leopold,  Breslau,  Beck,  and  Wyder,  have  reported  cases  in  which  they 
believed  that  polypi  projecting  into  the  lumen  of  the  tube  caused  the  arrest  of  the 
ovum.  It  would  appear,  however,  that  only  the  cases  of  Beck  and  Wyder  are 
at  all  convincing,  as  only  in  them  were  the  polypi  situated  between  the  fetal 
sac  and  the  uterus.  Moreover,  it  is  quite  possible,  as  Ahlfeld  has  pointed  out, 
that  even  they  had  nothing  to  do  with  the  arrest  of  the  ovum,  but  were  merely 
secondary  decidual  outgrowths.  De  la  Faille  considered  that  a  similar  explana- 
tion might  be  invoked  for  one  of  his  cases  of  interstitial  pregnancy,  as  he  found  the 
proximal  extremity  of  the  tube  occluded  by  a  portion  of  the  uterine  decidua. 

Tumors  of  the  Tube  Wall.— Petit,  Diihrsseri,  and  others  have  described 
myomata  in  the  tube  wall,  which  they  believed  so  compressed  its  lumen  as  to  inter- 
fere with  the  passage  of  the  ovum;  while  in  other  instances  tumors  arising  from 
surrounding  organs  are  believed  to  have  played  a  similar  part. 

Salpingitis.— Schroeder  in  1877,  but  more  particularly  Tait,  a  few  years  later, 
advanced  the  theory  that  the  most  frequent  cause  of  tubal  pregnancy  was  to  be  found 
in  endosalpingitis.  These  authorities  held  that  fertilization  normally  occurred  in 
the  uterine  cavity,  and  was  facilitated  by  the  fact  that  the  ciliary  current  was  directed 
from  below  upward  in  the  uterus  and  from  above  downward  in  the  tubes,  so  that 


132  EXTRAUTERINE  PREGNANCY. 

the  spermatozoa  were  readily  carried  upward  to  the  fundus,  but  were  prevented 
from  gaining  access  to  the  tubes.  Accordingly,  they  supposed  if  the  cilia  of  the 
tube  had  been  destroyed  as  a  result  of  salpingitis,  that  there  would  no  longer  be 
any  obstacle  to  the  ascent  of  the  spermatozoa;  while  at  the  same  time  the  downward 
passage  of  the  ovum  would  be  rendered  very  difficult. 

Recent  work,  however,  has  demonstrated  the  fallacy  of  these  arguments.  In 
the  first  place,  Hofmeier  and  Mandl  have  shown  that  the  ciliary  current  is  directed 
from  above  downward  from  the  fimbriated  end  of  the  tubes  to  the  internal  os,  and 
therefore  the  spermatozoa  are  obliged  to  work  against  the  current  from  the  time 
they  pass  the  cervix.  More  important  is  the  fact  that  experiments  upon  animals 
and  a  few  observations  upon  human  beings  show  that  a  few  hours  after  copula- 
tion spermatozoa  can  be  found  in  the  lateral  portion  of  the  tubes,  and  even  upon 
the  surface  of  the  ovary.  Accordingly  it  would  appear  that  the  lateral  end  of  the 
tube  may  be  regarded  as  a  receptaculum  seminis,  and  that  conception  normally 
occurs  in  that  location  or  upon  the  surface  of  the  ovary.  Consequently  every  preg- 
nancy is  extrauterine  in  its  early  stages,  and  the  problem  to  be  solved  is  not  how 
the  ovum  and  spermatozoa  meet  in  the  tube,  but  why  the  fertilized  ovum  usually 
descends  into  the  uterus. 

Tait's  theory  has  found  many  adherents,  but  careful  study  of  the  specimens 
obtained  at  operation  appears  to  show  that  it  is  without  foundation  in  the  majority 
of  cases.  In  nearly  every  specimen  which  I  have  examined  I  have  been  able  to 
demonstrate  the  presence  of  cilia  in  the  pregnant  tube,  and  similar  observations 
have  been  made  by  Hofmeier  and  Zedel,  the  latter  having  observed  them  in  motion 
in  three  out  of  the  four  specimens  which  he  examined  immediately  after  operation. 
This,  however,  does  not  demonstrate  that  salpingitis  plays  no  part  in  the  production 
of  extrauterine  pregnancy. 

The  views  of  Schroeder  and  Tait  were  promptly  accepted  by  most  authorities, 
and  at  the  present  time  are  still  held  in  a  modified  way  by  many  writers,  among 
whom  may  be  mentioned  Martin,  Diihrssen,  Fehling,  Mandl  and  Schmidt,  Ott, 
Kiistner,  Petersen,  Runge,  and  others.  The  etiologic  connection  is  borne  out  by 
two  facts:  first,  that  one  is  able  to  elicit  a  history  of  previous  inflammatory  trouble 
in  the  majority  of  cases,  and,  second,  that  in  many  instances  careful  histologic 
examination  reveals  traces  of  past  or  present  inflammation,  which  frequently  in- 
volves both  tubes. 

Following  the  demonstration  that  Tait's  original  theory  was  incorrect,  great 
difficulty  was  experienced  in  formulating  a  satisfactory  explanation  for  the  fact 
that  salpingitis  facilitated  the  occurrence  of  tubal  pregnancy;  and  most  writers 
were  obliged  to  be  content  with  merely  demonstrating  that  inflammatory  lesions 
were  present  in  a  certain  percentage  of  their  cases.  Thus,  Ott  and  Petersen  could 
elicit  an  inflammatory  history  in  all  of  their  cases,  Runge  in  most  of  his,  while 
Mandl  and  Schmidt,  and  Diihrssen  stated  that  66  and  68.7  per  cent,  of  their  pa- 
tients had  suffered  from  gonorrhea.  Negative  evidence  was  offered  by  Ahlfeld, 
who  believes  that  the  infrequent  occurrence  of  tubal  pregnancy  in  his  experience 


CONDITIONS    INTERFERING   WITH   PASSAGE    OF   OVUM.  133 

may  be  explained  by  the  fact  that  his  material  comes  from  a  country  district  where 
gonorrhea  occurs  but  rarely. 

In  1902  Opitz  found  definite  inflammatory  lesions  in  15  out  of  23  specimens  from 
Olshausen's  clinic,  and  in  every  instance,  whether  such  lesions  were  present  or 
not,  noted  that  the  tips  of  many  of  the  folds  of  the  mucosa  had  become  fused 
together,  so  that  the  microscopic  sections  frequently  presented  the  cribriform 
appearance  characteristic  of  follicular  salpingitis.  Moreover,  he  found  similar 
lesions  in  the  non-pregnant  tube,  wherever  it  was  available  for  examination. 

He  held  that  such  a  condition  afforded  a  very  satisfactory  explanation  for  the 
arrest  of  the  ovum,  as  he  assumed  that  some  of  the  canals  inclosed  between  the  adhe- 
rent folds  ended  blindly  at  one  end,  but  communicated  freely  with  the  main  lumen 
at  the  other.  Accordingly,  it  would  only  be  necessary  for  the  fertilized  ovum  to 
enter  one  of  these  cul-de-sacs  in  order  to  be  arrested,  and  thus  lead  to  the  develop- 
ment of  a  tubal  pregnancy.  Similar  observations  have  been  made  by  Micholitsch 
and  others,  and  can  be  confirmed  by  any  observer. 

This  explanation  has  been  enthusiastically  accepted  by  Werth,  who  considers 
it  of  almost  universal  application.  It  is  interesting  to  note  that  he  described  a  simi- 
lar condition  in  his  monograph  of  1887,  but  did  not  recognize  its  significance.  I 
have  frequently  made  the  same  observation,  and  while  I  consider  that  such  a  condi- 
tion may  cause  the  arrest  of  a  fertilized  ovum,  I  am  inclined  to  agree  with  Kermauner 
that  we  should  hesitate  before  giving  it  a  too  general  acceptance. 

Diverticula  from  the  Lumen  of  the  Tube. — In  1891  Landau  and  Rheinstein 
and  myself  demonstrated  the  presence  of  epithelial  canals  in  the  muscular  wall  of 
the  tube,  and  showed  by  means  of  serial  sections  that  one  end  communicated  w^ith 
its  main  lumen,  while  the  other  ended  blindly.  We  both  suggested  that  a  fertilized 
ovum  might  occasionally  become  arrested  at  the  blind  end  of  such  a  structure  and 
thus  give  rise  to  a  tubal  pregnancy;  and  Landau  and  Rheinstein  described  a  speci- 
men which  they  believed  demonstrated  such  a  mechanism. 

For  some  years  I  believed  firmly  in  this  mode  of  origin,  and  thought  that  I  had 
studied  a  number  of  specimens  which  demonstrated  its  correctness.  These  were 
cases  of  early  tubal  pregnancy,  in  which  the  product  of  conception  lay  in  the  muscu- 
lar wall  of  the  tube,  entirely  outside  of  its  lumen.  Further  study,  however,  has  led 
me  to  believe  that  my  conclusions  were  erroneous,  and  that  the  findings  upon  which 
they  were  based  in  reality  represent  the  normal  mode  of  implantation  of  the  ovum 
in  the  tube,  and  are  entirely  independent  of  the  existence  of  diverticula.  This  ques- 
tion, however,  will  be  considered  more  in  detail  in  the  paragraphs  devoted  to  the 
anatomy  of  the  pregnant  tube.  At  the  same  time  I  do  not  wish  to  deny  the  possi- 
bility of  the  arrest  of  an  ovum  in  such  structures,  as  I  believe  that  it  occasionally 
occurs. 

During  the  past  few  years  Goebel,  Opitz,  Micholitsch,  Fellner,  and  others  have 
devoted  considerable  attention  to  this  subject,  and  have  shown  that  diverticula  from 
the  lumen  of  the  tube  are  of  frequent  occurrence,  and  hold  that  they  play  an  impor- 
tant part  in  the  etiology  of  tubal  pregnancy.     In  fact,  Fellner  states  that  they  are 


134 


EXTRAUTERINE   PREGNANCY. 


the  usual  cause  of  the  condition,  and  beheves  that  its  non-occurrence  in  the  lower 
animals  is  to  be  attributed  to  the  absence  of  such  structures. 

It  is  generally  considered  that  such  diverticula  are  congenital  in  origin  and  repre- 
sent abortive  attempts  at  the  formation  of  accessory  tubal  ostia.  The  investigations 
of  Hoehne,  however,  show  that  such  is  not  always  the  case;  as  he  has  been  able  to 
demonstrate,  in  one  specimen  at  least,  that  they  may  result  from  a  secondary 
extension  of  the  tubal  epithelium  into  the  cavities  of  small  intramural  abscesses 
which  have  ruptured  into  the  lumen  of  the  tube. 

In  exceptional  instances  serial  sections  through  the  tubes  demonstrate  the  pres- 
ence of  abnormal  lumina.  These  may  vary  from  canals  which  extend  almost  its 
entire  length,  and  represent  an  abortive  attempt  at  the  formation  of  an  accessory 
tube,  to  processes  of  varying  length  which  extend  from  the  lumen  of  the  tube  and 
continue  parallel  to  it  for  a  certain  distance,  and  then  either  rejoin  it  or  end 
blindly.  I  have  studied  one  specimen  in  which  the  ovum  was  probably  arrested 
in  such  a  structure,  while  Henrotin  and  Herzog,  and  Franque  and  Garkisch  have 
described  cases  in  which  such  a  mode  of  origin  was  conclusively  demonstrated. 

Occasionally  accessory  tubal  ostia  may  play 
a  part  in  the  etiology  of  the  affection,  and 
Sanger  has  reported  a  case  in  which  the  ovum 
gained  access  through  such  a  structure  to  a 
tube  whose  fimbriated  extremity  was  firmly 
occluded.  Frequently  what  appears  at  first 
glance  as  an  accessory  ostiimi  does  not  com- 
municate with  the  lumen  of  the  tube,  but 
merely  represents  a  small  cul-de-sac,  in  which 
the  fertilized  ovum  may  occasionally  be 
arrested,  as  was  conclusively  demonstrated 
in  a  specimen  described  by  Henrotin  and 
Herzog  (Fig.  421). 
In  this  connection  it  may  be  interesting  to  refer  to  the  cases  recently  reported  by 
Hofmeier  and  by  Potocki.  The  former  removed  the  left  tube,  whose  uterine  end  was 
the  seat  of  a  ruptured  pregnancy;  and  six  months  later  again  operated  upon  the 
same  woman  for  intra-abdominal  hemorrhage.  To  his  great  surprise,  he  found  an 
early  pregnancy  arising  distal  to  the  ligature  upon  the  stump  of  the  amputated 
tube.  In  Potocki's  case  pregnancy  followed  the  removal  of  the  left  tube  and 
ovary  and  the  excision  of  a  myoma  from  the  left  side  of  the  uterus.  The 
fetal  sac  was  attached  beneath  the  left  cornu  and  communicated  with  the 
uterine  cavity,  while  the  tubal  stump  from  the  previous  operation  was  impervious. 
After  careful  study  the  author  concluded  that  the  ovum  had  become  arrested,  at 
the  outer  end  of  a  fistulous  tract,  which  had  followed  the  removal  of  the  myoma, 
and  considers  that  the  nearest  approach  to  a  similar  condition  was  afforded  by  the 
celebrated  case  of  Lecluyse. 

Congenital  Narrowing  of  Tubal  Lumen. — Runge  in  1904,  and  Franque  and 


EiG.  421. — Pregxaxct  in  Accessory  Tubal 

Ostium  (Henrotin  and  Herzog). 

A,  Small   accessory  ostium;    B,  opening 

of  pregnant   ostium;     C,   blind  end  of  same; 

D,  blood-clot  containing  remnants  of  ovum. 


CONDITIONS    INTERFERING    WITH   PASSAGE    OF   OVUM.  135 

Garkisch  in  1905,  invoked  such  a  condition  as  an  occasional  etiologic  factor.  In 
Runge's  case  the  lumen  of  the  tube  proximal  to  the  pregnancy  was  reduced  to  one- 
twentieth  of  its  normal  caliber. 

Persistence  of  Fetal  Convolutions  of  the  Tube. — Ever  since  Freund  and 
Schrober  had  demonstrated  the  part  which  persistence  of  the  convolutions,  which 
characterize  the  tube  in  early  life,  may  play  in  the  production  of  tubal  diseases,  a 
certain  number  of  authors  have  held  that  such  a  condition  may  occasionally  give 
rise  to  extrauterine  pregnancy,  either  by  constricting  the  lumen  of  the  tube  or  by 
interfering  with  its  peristalsis.  This  condition  has  been  invoked  as  an  etiologic 
factor  by  Abel,  Goebel,  Kreisch,  and  others. 

Puerperal  Atrophy  of  the  Tube. — Diihrssen  pointed  out  that  some  of  his  cases 
of  extrauterine  pregnancy  occurred  within  one  year  or  less  after  a  normal  labor, 
and  in  two  instances  while  the  mother  was  still  suckling  her  child.  In  such  instances 
he  believes  that  a  puerperal  atrophy  of  the  muscularis  of  the  tube  had  so  impaired 
its  peristalsis  as  to  interfere  with  the  downward  propulsion  of  the  ovum,  and  forti- 
fies his  assertion  by  an  illustration  in  which  the  tube  presents  a  markedly  atrophic 
appearance. 

External  Migration  of  the  Ovum. — Every  one  who  has  carefully  studied 
the  anatomic  conditions  in  a  considerable  number  of  extrauterine  pregnancy  speci- 
mens has  noted  the  frequent  occurrence  of  external  migration  of  the  ovum:  that  is, 
finding  the  corpus  luteum  in  one  ovary  and  the  pregnancy  in  the  opposite  tube. 
I  have  noted  it  in  at  least  one-fourth  of  my  cases,  but  am  unable  to  state  whether 
it  is  peculiar  to  tubal  pregnancy,  since  comparatively  few  opportunities  occur  for 
ascertaining  how  frequently  it  occurs  in  normal  uterine  pregnancy. 

Attention  was  first  directed  to  this  condition  by  Kussmaul,  while  Schrenck, 
Kustner,  Kermauner,  and  others  have  especially  insisted  upon  its  incidence  in  ex- 
trauterine pregnancy.  Moreover,  Sippel  has  pointed  out  that  occasionally  under 
such  circumstances  the  transit  may  be  delayed  so  long  that  the  ovum  undergoes 
such  development  as  to  interfere  with  its  passage  through  the  narrower  parts 
of  the  tube. 

Hitschmann  and  Lindenthal  upon  purely  theoretic  grounds  advanced  a  some- 
what similar  explanation  for  cases  not  associated  with  external  migration. 

Obstruction  by  Twin  Ova. — In  view  of  the  relative  frequency  of  combined 
tubal  and  uterine  twin  pregnancy,  of  which  Parry  collected  23  in  his  500  cases  of 
extrauterine  pregnancy,  Barnes  supposed  that  the  arrest  of  one  ovum  in  the  tube 
might  be  attributed  to  the  two  ova  mutually  interfering  with  one  another,  so  that 
one  was  retarded  until  it  had  become  too  large  to  pass  on  to  the  uterus. 

This  view,  however,  possesses  only  a  historic  interest,  as  the  vast  literature  of 
recent  years  shows  that  combined  pregnancy  occurs  far  less  frequently  than  Parry 
thought.  Moreover,  in  several  of  the  cases,  which  have  been  carefully  investigated, 
such  an  explanation  could  not  be  considered,  for  the  reason  that  the  presence  of 
corpora  lutea  in  each  ovary  indicated  that  the  two  ova  had  descended  separate 
tubes. 


136  EXTRAUTERINE  PREGNANCY. 


PHYSICAL  AND  DEVELOPMENTAL  CONDITIONS  WHICH  FAVOR  DECIDUAL 
FORMATION  IN  THE  TUBES. 

This  theory  owes  its  origin  to  Webster,  who  could  not  accept  any  of  the  large 

number  of  theories  which  had  been  advanced  up  to  this  time.     After  considering 

the  embryology  of  the  genital  tract,  and  emphasizing  the  well-known  fact  that  both 

the  tubes  and  the  uterus  were  originally  derived  from  the  Miillerian  ducts,  he  stated 

that  there  was  no  inherent  reason  why  an  ovum  should  not  become  implanted  upon 

the  upper  as  well  as  upon  the  lower  part  of  this  canal.     Consequently,  the  only 

explanation  which  he  could  offer  for  its  infrequent  occurrence  was  that  the  decidual 

reaction  which  occurs  so  promptly  and  decidedly  in  the  uterus,  in  the  presence  of  a 

fertilized  ovum,  is  usually  lacking  in  the  tubes.     Such  a  reaction  he  considered  a 

reversion  to  an  earlier  type,  and  therefore  a  sign  of  degeneracy. 

This  view  was  soon  indorsed  by  a  number  of  writers,  among  whom  may  be  men- 
tioned Pantellani,  Mandl  and  Schmidt,  Wormser,  and  Moericke,  but  without  an- 
atomic data.  Notwithstanding  the  fact  that  most  recent  investigators  believe  that  the 
decidua  is  entirely  lacking  or  only  comparatively  slightly  developed  in  the  pregnant 
tube,  Webster  still  holds  to  this  theory.  In  1904,  when  describing  an  undoubted  case 
of  ovarian  pregnancy,  he  stated  that  he  did  not  believe  that  implantation  could  occur 
outside  of  the  Miillerian  tract;  and,  in  order  to  bring  his  observation  into  harmony 
with  such  a  theory,  he  contended  that  fragments  of  Miillerian  tissue  must  have 
become  incorporated  into  the  ovary. 

More  or  less  closely  connected  with  Webster's  theory  is  the  view  advanced  by 
Sippel,  who,  as  stated  above,  noted  external  migration  of  the  ovum  in  a  considerable 
proportion  of  his  cases.  He  believes  that  a  certain  time  must  elapse  after  fertili- 
zation before  a  decidual  reaction  can  occur,  and  that  the  ovum  has  usually  reached 
the  uterus  before  this  happens;  but  that  in  external  migration  the  time  consumed  by 
the  ovum  in  making  the  transit  through  the  peritoneal  cavity  may  be  sufficient  to 
allow  the  tube  to  exhibit  such  a  reaction. 

From  what  has  just  been  said,  it  is  apparent  that  there  is  no  lack  of  theories 
concerning  the  etiology  of  extrauterine  pregnancy,  and  the  question  which  we  have 
to  consider  is  which  of  them  is  correct,  or  whether  any  one  is  of  universal  application. 

Theoretically  it  would  appear  that  certain  of  the  mechanical  conditions  mentioned 
above  must  frequently  play  a  part  in  the  production  of  the  affection.  On  the  other 
hand,  it  must  be  admitted  that  diverticula  from  the  lumen  of  the  tube  and  the  so- 
called  folhcular  salpingitis  are  frequently  noted,  while  tubal  pregnancy  occurs  but 
comparatively  rarely. 

The  greatest  blow,  however,  which  these  theories  have  suffered  is  from  the  ex- 
perimental work  of  Tainturier,  and  Mandl  and  Schmidt.  These  investigators  ap- 
plied ligatures  to  various  parts  of  the  genital  tract  of  rabbits  shortly  after  copulation. 
When  the  ligature  was  applied  to  one  uterine  cornu,  some  distance  below  the  tubal 
opening,  ova  developed  distal  to  the  ligature,  as  well  as  in  the  normal  horn.  AMiere 
both  cornua  were  ligated,  ova  developed  only  distal  to  the  ligatures;  on  the  other 


OVARIAN    PREGNANCY.  137 

hand,  when  the  hgatures  were  appKed  to  the  uterine  end  of  the  tubes,  extrauterine 
pregnancy  did  not  develop,  although  dead  ova  could  be  demonstrated  in  them.  In 
a  series  of  control  experiments  only  one  tube  was  ligated,  when  the  same  result  was 
obtained  on  that  side,  while  the  other  horn  contained  normal  embryos. 

These  experiments  apparently  show  that,  in  the  rabbit  at  least,  some  other  fac- 
tor than  mere  mechanical  interference  with  the  downward  passage  of  the  ovum  is 
essential  to  the  production  of  tubal  pregnancy,  and  this  Mandl  and  Schmidt  sought 
in  a  preliminary  decidual  reaction.  The  fact,  however,  that  the  recent  work 
upon  the  anatomy  of  the  pregnant  tube  shows  that  the  decidual  formation  is  never 
abundant,  and  is  frequently  altogether  absent,  would  militate  strongly  against  such 
a  view.  The  only  positive  experimental  work  along  these  lines  was  reported  by 
Nuck  many  years  ago,  but  it  is  probably  open  to  the  objection  that  he  did  not  dis- 
tinguish carefully  between  the  uterine  cornua  and  tubes  in  the  lower  animals. 

The  idea  that  the  affection  is  a  sign  of  degeneration  or  reversion,  while  extremely 
interesting  and  to  a  certain  extent  borne  out  by  facts,  cannot  be  accepted  as  a  uni- 
versal solution  for  the  problem;  for  in  many  instances  the  condition  occurs  in 
perfectly  healthy  women  who  live  amid  the  best  surroundings.  Moreover,  its 
great  rarity  in  the  lower  animals  also  speaks  against  such  a  view,  and  Bland-Sutton 
states  that  in  his  large  experience  in  the  zoological  gardens  of  London  he  has  never 
met  with  tubal  pregnancy  in  animals,  and  believes  that  all  such  cases  recorded  in 
the  literature  are  due  to  uterine  rupture,  or  to  confounding  the  uterine  cornua  with 
the  tubes.  This  statement,  however,  appears  somewhat  too  radical,  as  Waldeyer 
has  reported  an  undoubted  case  in  an  ape. 

In  view  of  the  considerations  adduced,  it  is  apparent  that  there  is  no  universal 
cause  for  extrauterine  pregnancy.  In  many  instances  the  arrest  of  an  ovum  in  a 
crypt  resulting  from  follicular  salpingitis,  or  in  a  diverticulum  from  the  lumen  of  the 
tube,  may  afford  a  satisfactory  explanation;  though  in  a  certain  proportion  of  cases 
even  the  most  careful  history  of  the  patient  and  thorough  microscopic  examination 
of  the  specimen  will  fail  to  reveal  a  tangible  cause  for  the  condition,  which  will  then 
remain  as  great  a  problem  to  us  as  to  our  predecessors. 

Classification. 

The  fertilized  ovum  may  be  arrested  at  any  point  on  its  way  from  the  follicle  in 
which  it  originated  to  the  uterine  cavity,  and  accordingly  may  undergo  development 
in  either  the  ovary  or  the  tube,  giving  rise  to  ovarian  or  to  tubal  pregnancy.  There 
is,  however,  considerable  doubt  as  to  whether  it  can  become  implanted  upon  the  peri- 
toneum and  lead  to  a  primary  abdominal  pregnancy.  We  shall  consider  each  of 
these  groups  in  detail. 

OVARIAN  PREGNANCY. 
Ovarian  pregnancy  was  first  described  by  Mercerus  in  1614  and  by  St.  INIaurice 
in  1682,  after  which  it  was  generally  recognized,  and  was  included  by  both  Bianchi 
and  Boehmer  in  their  classifications  of  extrauterine  pregnancy. 


138  EXTRAUTERINE  PREGNANCY. 

Its  existence  was  generally  admitted  until  1835,  when  Velpeau  stated  that  it  was 
impossible  to  adduce  conclusive  evidence  of  the  ovarian  nature  of  any  of  the  cases 
which  had  been  described  up  to  that  time.  Likewise  in  1847  Mayer,  a  pupil  of 
Bischoff,  positively  denied  the  possibility  of  its  occurrence,  and  held  that  all  cases 
which  had  been  described  as  such  had  been  incorrectly  interpreted.  Similar  views 
were  also  expressed  by  Allan  Thompson  and  Pouchet.  Their  skepticism  was 
probably  fully  justified  at  the  time,  as  many  of  the  cases  collected  by  Campbell 
and  Collet  Y.  Gurgui  were  simple  dermoid  cysts. 

On  the  other  hand,  all  German  authorities,  with  the  exception  of  Mayer,  have 
admitted  its  possibiUty,  and  Kiwisch  in  1851  described  a  case  which  he  considered 
conclusive. 

Prior  to  1900  the  possibility  of  the  occurrence  of  ovarian  pregnancy  was  almost 
universally  denied  by  English  writers,  among  whom  may  be  mentioned  Tait,  Web- 
ster, Cullingworth,  Bland-Sutton,  and  Taylor.  Indeed,  as  far  as  I  can  ascertain, 
only  three  cases  were  reported  in  England  during  the  nineteenth  century;  namely, 
two  by  Granville  in  1834,  and  one  by  Oliver  in  1896.  In  this  country  most  writers 
have  followed  the  English  authorities,  although  Parry  admitted  its  existence,  and 
not  a  few  operators  have  reported  doubtful  cases;  but  it  was  not  until  1902  that 
Thompson  demonstrated  a  perfectly  conclusive  specimen. 

At  the  present  time  no  one  doubts  the  possibility  of  ovarian  pregnancy,  and  even 
such  critics  as  Bland-Sutton  and  Webster  have  been  compelled  to  admit  that  their 
previous  skepticism  was  not  justified. 

Up  to  1878  there  existed  no  definite  criteria  by  which  such  cases  could  be  judged, 
and  many  specimens  were  described  as  ovarian  pregnancy  which  had  no  claim  to 
such  a  title.  In  that  year,  however,  Spiegelberg  reported  what  he  believed  to  be  a 
conclusive  case,  and  formulated  certain  conditions  which  he  held  must  be  fulfilled 
in  order  to  justify  such  a  diagnosis.  He  demanded:  (1)  that  the  tube  on  the  af- 
fected side  be  intact;  (2)  that  the  fetal  sac  occupy  the  position  of  the  ovary;  (3) 
that  it  be  connected  with  the  uterus  by  the  ovarian  ligament;  and  (4)  that  definite 
ovarian  tissue  be  found  in  its  wall.  When  judged  by  these  criteria,  the  majority 
of  cases  which  had  been  described  up  to  his  time  were  found  wanting,  and  subse- 
quent investigation  has  shown  that  a  number  of  cases  which  he  considered  conclu- 
sive are  likewise  open  to  very  considerable  doubt. 

Werth,  on  the  other  hand,  maintains  that  Speigelberg's  criteria  are  too  rigid, 
and  that  their  appHcation  would  rule  out  many  specimens  concerning  whose  origin 
there  is  but  little  doubt.  Accordingly,  he  states  that  one  should  consider  as  ovarian 
any  fetal  sac  which  is  connected  with  the  uterus  and  broad  ligament  in  such  a  man- 
ner as  to  demonstrate  its  adnexial  origin,  when  it  can  also  be  clearly  shown  that  the 
tube,  including  the  fimbria  ovarica,  takes  no  part  in  its  formation,  provided  that  the 
possibility  of  pregnancy  in  an  accessory  tube  can  likewise  be  excluded. 

I  cannot  accept  Werth's  teachings,  as  I  feel  that  their  general  adoption  would 
lead  to  many  cases  being  described  as  ovarian  pregnancy  which  have  no  claim  to  be 
designated  as  such.     Accordingly  I  consider  it  advisable  to  adhere  to  Spiegelberg's 


OVARIAN    PREGNANCY.  139 

criteria,  with  the  still  further  proviso  that  ovarian  tissue  must  be  demonstrated  not 
only  at  one  point,  but  in  several  portions  of  the  sac  wall,  tolerably  far  removed  from 
one  another.  To  my  mind,  this  modification  is  necessary  from  the  fact  that  in 
many  cases  of  tubal  and  broad  ligament  pregnancy  the  ovary  may  become  flattened 
out  and  incorporated  into  the  sac  wall  to  a  considerable  extent,  and  thus  lead  to  an 
erroneous  diagnosis. 

Of  course,  it  may  be  urged  that  such  rigid  criteria  may  occasionally  exclude 
from  consideration  certain  cases  in  which  the  characteristic  histologic  features  of 
the  ovarian  tissue  have  become  obliterated,  just  as  frequently  occurs  in  large  ovarian 
cystomata.  Such  an  objection  may  be  justified,  but  I  consider  that  the  interests 
of  science  will  be  better  served  by  excluding  an  occasional  case,  rather  than  by  re- 
porting large  numbers  of  doubtful  cases,  such  as  crowd  the  literature  at  present. 

Owing  to  the  omission  of  careful  microscopic  examination  these  criteria  are  ful- 
filled in  comparatively  few  of  the  reported  cases,  and  consequently  one  is  obliged  to 
classify  as  probable  or  highly  probable  a  number  of  cases  which  were  previously 
described  as  positive.  As  far  as  possible,  I  have  gone  over  the  cases  of  ovarian  preg- 
nancy reported  in  the  literature  up  to  July,  1906,  and  divided  them  into  four  groups: 
positive,  highly  probable,  fairly  probable,  and  doubtful,  according  to  the  extent  to 
which  the  above-mentioned  criteria  are  fulfilled.  At  the  same  time  I  must  admit 
that  such  a  classification  is  purely  arbitrary,  and  is  open  to  criticism,  as  it  is  often 
impossible  to  form  a  correct  estimate  of  a  specimen  from  a  written  description, 
especially  when  it  is  unaccompanied  by  illustrations.  Accordingly  while  the  num- 
ber of  cases  classed  as  positive  and  highly  probable  is  small,  the  classification  errs 
on  the  side  of  accuracy. 

I  have  classified  thirteen  cases  as  positive,  all  of  which  were  carefully  described 
and  studied  microscopically;  namely,  those  of  Gottschalk  (1893),  Ludwig  (1896), 
Kouwer  and  Tussenbroek  (1899),  Croft  (1900),  Anning  and  Littlewood  (1901), 
Robson  (1902),  Franz  (1902),  Thompson  (1902),  Mendes  de  Leon  and  Holleman 
(1902),  Michohtsch  (2  cases)  (1903),  Boesebeek  (1904),  Webster  (1904). 

The  cases  of  Gottschalk  and  Ludwig  had  gone  to  full  term.  In  the  former  the 
pregnancy  had  become  converted  into  a  lithopedion  and  had  been  carried  for  thirty 
years  before  its  removal;  while  in  the  latter  the  condition  was  associated  with  intra- 
uterine pregnancy,  which  terminated  spontaneously.  Several  days  later  Ludwig 
performed  laparotomy  successfully,  and  removed  a  living  child  and  the  gestation  sac. 

In  none  of  the  other  eleven  cases  had  the  pregnancy  progressed  beyond  the  fourth 
month,  and  all  the  specimens  were  most  carefully  described.  In  the  cases  of  Tus- 
senbroek, Anning  and  Littlewood,  and  Thompson  the  fetus  was  still  within  the  ovary; 
in  Croft's  case  it  was  in  the  abdomen,  but  connected  with  the  interior  of  the  ovary 
by  the  umbilical  cord;  while  in  Robson's  case  it  had  escaped  into  the  peritoneal 
cavity.  In  the  remaining  specimens  no  trace  of  a  fetus  could  be  discovered,  but 
the  ovary  contained  a  blood-stained  mass  of  tissue  in  which  chorionic  villi  and  fetal 
elements  could  be  positively  demonstrated. 

As  highly  probable  I  have  classified  seventeen  cases.     In  many  instances  there 


140  EXTRAUTERINE  PREGNANCY. 

is  practically  no  doubt  concerning  the  nature  of  the  specimens,  but  unfortunately 
some  had  not  been  examined  microscopically,  others  had  been  preserved  so  long  that 
accurate  differentiation  of  tissue  was  out  of  the  question,  while  in  a  third  group  the 
description  was  too  brief  to  permit  accurate  judgment.  In  nine  cases  the  pregnancy 
had  not  progressed  beyond  the  fourth  month:  those  of  Granville,  Hein,  Uhde, 
Gottschalk  (1886  and  1902),  Schenck,  Frank,  Simon,  and  Futh.  In  the  other 
eight  cases  it  had  advanced  to  or  beyond  term — Walter,  Spiegelberg,  Leopold,  Kiist- 
ner-Fick,  Herzfeld,  Martin,  Larsen,  and  Doche. 

Five  cases  may  be  designated  as  probable,  namely,  those  of  Patenko,  Puech, 
Geuer,  Gilford,  and  Toth.  The  first  four  were  from  the  early  and  the  last  case 
from  the  later  months  of  pregnancy.  Only  the  specimens  of  Patenko  and  Toth 
were  examined  microscopically,  but  in  neither  instance  were  the  findings  conclusive. 

On  the  other  hand,  the  evidence  in  favor  of  the  ovarian  nature  of  the  specimens 
described  by  Hecker,  Willigk,  Benicke,  Mann,  Sanger,  Wyder,  Winckel,  OHver, 
Bandel,  Lumpe,  and  Kantorowicz  is  so  imperfect  that  I  consider  them  as  doubtful. 

It  is  interesting  to  note  that  in  eleven  of  the  thirty-five  cases  which  I  have 
designated  as  positive,  highly  probable,  or  probable,  the  pregnancy  went  on  to  full 
term,  and  in  not  a  few  instances  gave  rise  to  lithopedion  formations,  which  had 
been  carried  for  years  before  removal.  This  would  appear  to  indicate  that  the 
ovary  can  accommodate  itself  more  readily  than  the  tube  to  the  growing  preg- 
nancy. At  the  same  time,  rupture  at  an  early  period  is  the  usual  termination,  as 
is  shown  by  the  fact  that  eleven  of  the  thirteen  positive  cases  had  not  progressed 
beyond  the  fourth  month. 

It  is  important  to  bear  in  mind  that  the  pregnancy  may  be  destroyed  at  an  early 
period,  without  rupture,  and  give  rise  to  a  tumor  of  varying  size,  consisting  of  a  cap- 
sule of  ovarian  tissue  inclosing  a  central  mass  made  up  of  a  blood-clot  and  chorionic 
villi,  and  may  or  may  not  contain  an  amniotic  cavity,  as  in  the  specimens  of  Mendes 
de  Leon  and  Webster.  Such  observations  make  it  appear  probable  that  a  certain 
proportion  of  ovarian  hematomata  may  actually  represent  the  remains  of  an  early 
pregnancy,  but  such  a  diagnosis  should  not  be  considered  unless  microscopic  ex- 
amination shows  the  presence  of  characteristic  chorionic  villi. 

According  to  Leopold,  ovarian  pregnancy  results  from  the  fertilization  of  the 
ovum  before  its  escape  from  the  Graafian  follicle.  Moreover,  he  believes  when 
several  follicles  mature  at  the  same  time,  that  a  deeply  lying  one  may  rupture  into 
a  more  superficial  one  without  the  escape  of  its  ovum,  which  may  be  fertilized  by 
spermatozoa  entering  through  the  superficial  follicle.  Such  an  occurrence  would 
afford  a  satisfactory  explanation  for  a  pregnancy  occupying  the  central  portion  of 
the  ovary.  Anatomic  evidence  in  favor  of  intrafollicular  fertilization  is  also  afforded 
by  the  fact  that  several  investigators,  following  the  example  of  Tussenbroek,  have 
demonstrated  corpus  luteum  cells  about  the  periphery  of  the  ovum. 

In  ovarian  pregnancy  the  ovum  itself  and  its  mode  of  implantation  do  not  differ 
essentially  from  that  observed  in  the  uterus,  except  that  a  definite  decidua  is  lacking, 
so  that  the  fetal  ectoderm  invades  the  ovarian  stroma  direcdy  and  opens  up  the 


TUBAL    PREGNANCY. 


141 


blood-vessels.  This  lack  of  decidual  tissue  has  been  commented  upon  by  every 
recent  investigator,  with  the  exception  of  Webster;  and  even  in  his  specimen  there 
is  a  strong  possibility  of  confusion  between  fetal  and  maternal  cells. 


TUBAL  PREGNANCY. 
This  is  by  far  the  most  frequent  variety  of  extrauterine  pregnancy,  and  according 
to  many  English  and  American  writers  the  only  form  with  which  we  have  to  deal. 
The  ovum  may  be  arrested  at  any  point  in  the  Fallopian  tube,  and,  depending 


^"^^lUlSSu^ , 


Fig.  422. — Unruptured  Ampullar  Pregnancy,  Four  Months. 


ut-.end 


upon  its  point  of  implantation,  we  distinguish  between  ampullar,  isthmic,  and  inter- 
stitial pregnancy.  Occasionally  implantation  may  occur  about  the  fimbriated  ex- 
tremity, and  very  exceptionally  even  upon  the  fimbria  ovarica.  From  these  primary 
forms  certain  secondary  varieties  occasionally  develop,  and  will  be  considered  later. 
According  to  Rosenthal,  interstitial  pregnancy  is  by  far  the  least  frequent  variety, 
occurring  in  less  than  3  per  cent,  of  the  1324  cases  which  he  collected  from  the  litera- 
ture. Weinbrenner  states  that  only  16  undoubted  cases  had  been  described  up  to 
1885,  which  had  increased  to  35  in  1904;  while  Werth  did  not  encounter  a  single 
example  in  120  operations  for  extrauterine  pregnancy.     Moreover,  Doran  has  stated 


142  EXTRAUTERINE  PREGNANCY. 

that  there  are  only  six  specimens  of  interstitial  pregnancy  in  the  museums  of  Lon- 
don, as  compared  with  almost  countless  numbers  of  the  other  varieties. 

The  statements  as  to  the  relative  frequency  of  the  isthmic  and  ampullar  forms 
of  tubal  pregnancy  vary  greatly.  Thus,  ]Mandl  and  Schmidt  contend  that  the  former 
occurs  more  frequently,  while  Martin  and  Orthmann  hold  the  opposite  \dew,  which 
is  confirmed  by  my  own  experience. 

Mode  of  Implantation  of  the  Ovum. — Until  the  appearance  of  Graf  Spec's 
work  upon  the  implantation  of  the  ovum  in  the  guinea-pig,  and  the  description  by 
Peters  of  a  very  young  human  ovum  embedded  in  the  uterine  mucosa,  our  views 
upon  the  subject  were  quite  erroneous  and  based  upon  purely  theoretic  consider- 
ations. Prior  to  that  time  it  was  generally  taught  that  a  well-developed  decidual 
formation  was  essential  to  the  normal  embedding  of  the  ovum,  and  that  in  the  tube, 
as  well  as  in  the  uterus,  a  definite  decidua  vera,  serotina,  and  reflexa  were  formed. 
Peters'  specimen,  however,  demonstrated  that  even  in  the  uterus,  a  definite 
decidua  is  not  necessary,  as  it  clearly  showed  that  the  ovum  had  burrowed  down  into 
the  depths  of  an  edematous  endometrium,  whose  stroma  cells  had  not  yet  assumed  a 
characteristic  decidual  appearance.     Moreover,  as  the  ovum  was  completely  shut 

off  from  the  uterine  cavity,  it  was  apparent 
that  the  decidua  reflexa  could  not  have  been 
formed,  as  was  previously  believed,  by  an 
upgrowth  from  the  decidua  vera,  but  rather 
that  it  had  resulted  from  a  cleavage  of  the 
portion    of   decidua   immediately   above    the 

Fig.  423.— Isthmic  Pregnancy.  OVUm. 

Rupture  ten  days  after  last  menstrual  period.  Tllis    WOrk,  which   haS    Completely    revolu- 

tionized our  conception  of  the  implantation 
of  the  ovum  in  the  uterus,  as  well  as  of  the  development  of  the  placenta,  has 
been  shown  to  apply  equally  well  to  the  tube,  although  certain  of  its  anatomic 
peculiarities  usually  necessitate  a  different  outcome. 

Even  before  the  appearance  of  Peters'  work  it  had  become  apparent  that  the 
old  views  could  not  be  accepted  in  their  entirety  as  far  as  tubal  pregnancy  was  con- 
cerned. Thus,  Bland-Sutton  in  1891,  and  Fiith  and  Griffiths  a  few  years  later, 
pointed  out  that  the  decidual  reaction  in  the  tube  was  nothing  like  so  extensive  as 
was  generally  believed;  while  Kiihne,  Aschoff,  and  Kreisch  in  1899  cast  grave 
doubts  upon  its  existence,  and  contended  that  the  cells  which  were  usually  described 
as  decidual  were  really  derived  from  the  fetal  trophoblast.  ^Moreover,  beginning 
with  Rokitansky  a  certain  number  of  investigators  had  been  very  skeptical  con- 
cerning the  development  of  a  typical  decidua  reflexa  in  tubal  pregnancy. 

The  ovum  may  become  arrested  at  any  portion  of  the  tube,  and  according  to 
Werth  its  implantation  may  be  of  the  columnar  or  intercolumnar  variety.  In  the 
former,  which  is  of  very  rare  occurrence,  the  ovum  becomes  attached  to  one  of  the 
folds  of  the  mucosa,  while  in  the  latter  it  becomes  implanted  at  the  peripheral 
part  of  the  lumen  in  a  depression  between  two  folds. 


TUBAL   PREGNANCY. 


143 


In  either  event  the  ovum  does  not  remain  upon  the  surface,  but  at  once  makes 
its  way  through  the  tubal  epithehum  and  comes  to  he  in  the  tissue  just  beneath  it. 
By  this  time  its  periphery  is  made  up  of  a  capsule  of  rapidly  proliferating  ectodermal 
cells — the  trophoblast.  These  cells  rapidly  invade  the  surrounding  tissues,  and, 
as  the  tube  does  not  possess  a  submucosa,  almost  immediately  come  in  contact  w4th 
the  underlying  muscularis,  and  make  their  way  between  its  fibers. 

The  trophoblastic  cells  not  only  possess  markedly  invasive  properties  in  virtue 
of  their  rapid  proliferation,  but  also  exert  an  erosive  action  upon  the  surrounding 
maternal  tissue.  As 
a  consequence  many 
of  the  muscle  cells  are 
destroyed  and  under- 
go fibrinous  degenera- 
tion, while  the  blood- 
vessels in  the  vicinity 
are  opened  up  by  the 
invading  trophoblast 
and  by  the  escape  of 
their  contents  give  rise 
to  a  large  number  of 
spaces  of  varying  size 
filled  with  blood,  which 
lie  entirely  within  the 
trophoblast,  or  be- 
tween it  and  the  sur- 
rounding maternal  tis- 
sue. \  ^  -j;.;^ 

This  represents  the 
earliest  stage  in  the 
formation  of  the  inter- 
villous spaces  and  the 
placental  circulation. 
At  the  same  time, 
fetal  mesoderm  grows 
down  into  the  masses 
of  trophoblast  which 
bound  the  blood-spaces,  and  converts  them  into  rudimentary  chorionic  villi,  which 
possess  a  core  of  stroma  and  a  periphery  made  up  of  many  layers  of  fetal  ectoderm. 
As  the  process  goes  on,  these  rudimentary  villi  gradually  assume  the  arborescent 
form  characteristic  of  fully  developed  chorionic  villi,  which  then  consists  of  a  con- 
nective-tissue stroma  covered  by  two  layers  of  epithelium — Langhans'  layer  within 
and  syncytium  without. 

Until  definite  villi  have  become  developed,  it  would  seem  that  the  entire  fetal 


-  M.  ^V-.Tii-Vll 


Fig.  424. — Early  Tubal  Pregnancy,  showing  Ovum  Embedded  in  Wall 

OF  Tube  Outside  of  Lumen.     X  6. 

b.  c,  Blood-clot;  v.,  chorionic  villi;  refl.,  pseudo-reflexa. 


144  EXTRAUTERINE  PREGNANCY. 

ectoderm  possesses  invasive  and  erosive  properties,  but  afterward  such  action 
becomes  restricted  to  the  groups  of  cells  which  serve  to  attach  the  tips  of  the  larger 
villous  stems  to  the  maternal  tissue. 

In  the  usual  or  intercolumnar  mode  of  implantation  the  ovum,  as  soon  as  it  pene- 
trates the  epitheHum,  it  comes  to  lie  in  the  tube  wall  outside  of  its  lumen,  from  which 
it  is  separated  by  a  layer  of  tissue  of  varying  thickness — the  capsular  membrane  or 
pseudo-reflexa.  Fig.  424  gives  a  very  good  idea  of  intramural  embedding  of  the 
ovum.  In  the  very  rare  columnar  mode  of  implantation  the  ovum  lies  in  the  interior 
of  a  fold  of  mucosa,  and,  except  at  its  base,  is  surrounded  on  all  sides  by  tubal  mu- 
cosa, and  has  but  small  room  for  expansion. 

As  soon  as  I  became  acquainted  with  Peters'  views  concerning  the  mode  of  im- 
plantation of  the  ovum  in  the  uterus,  I  felt  convinced  that  exactly  the  same  process 
occurred  in  the  tube,  and  each  additional  specimen  of  early  tubal  pregnancy  which  I 
have  studied  has  served  to  confirm  my  impression.  When  considering  the  question  of 
the  arrest  of  the  ovum  in  tubal  diverticula,  I  stated  that  further  study  had  convinced 
me  that  many  specimens,  which  I  once  thought  afforded  satisfactory  proof  of  such  an 
occurrence,  should  be  regarded  as  excellent  examples  of  the  normal  process  of  intra- 
mural embedding  of  the  ovum.  That  I  do  not  stand  alone  in  this  belief  is  shown 
by  the  fact  that  nearly  every  investigator  who  has  studied  the  matter  in  recent  years 
has  arrived  at  the  same  conclusion.  And  I  need  only  mention  that  it  is  indorsed 
by  Fiith,  Griffiths,  Aschoff,  Kiihne,  Petersen,  Andrews,  Couvelaire,  Lockyer,  Werth, 
Pfannenstiel,  Kromer,  Voigt,  Kermauner,  Heinsius,  Berkeley  and  Bonney,  Wall- 
gren  and  many  other  observers  to  indicate  how  general  has  been  its  acceptance. 

The  further  development  of  the  pregnancy  depends  in  great  part  upon  the 
portion  of  the  tube  in  which  implantation  has  occurred.  When  in  the  ampulla, 
the  growing  ovum  pushes  forward  its  capsular  membrane  into  the  tubal  lumen, 
and  the  latter  may  eventually  become  so  compressed  as  to  form  a  mere  crescentic 
slit,  whose  walls  are  almost  in  apposition.  If  the  course  of  the  pregnancy  is  not 
interrupted,  the  capsular  membrane  may  fuse  with  the  neighboring  mucosa,  so  that 
eventually  all  trace  of  the  lumen  may  disappear  in  the  immediate  vicinity  of  the 
pregnancy.  On  the  other  hand,  when  implantation  occurs  in  the  isthmus,  and 
particularly  in  the  portion  immediately  adjoining  the  uterus,  the  small  size  of  the 
lumen  precludes  the  possibility  of  such  expansion,  and  as  a  consequence  the  ovum 
invades  the  tube  wall  peripherally  to  the  lumen,  so  that  the  latter  may  eventually 
become^almost  completely  separated  from  the  underlying  muscularis  and  surrounded 
by  fetal  tissue  and  chorionic  villi  (Fig.  425). 

Decidua. — As  has  already  been  indicated,  it  was  formerly  held  that  a  typical 
decidua  vera  and  serotina  were  developed  in  every  case  of  tubal  pregnancy;  and 
it  was  not  until  the  work  of  Bland-Sutton  in  1891,  and  particularly  of  Kiihne  and 
Aschoff  in  1899,  that  its  existence  was  seriously  doubted.  The  last-named  investi- 
gators, however,  pointed  out  that  the  cells  which  had  been  previously  described  as 
decidual  were  of  fetal  origin  and  represented  descendants  of  the  original  tropho- 
blast,  and  contended  that  it  was  very  questionable  whether  a  decidual  reaction 


TUBAL  PREGNANCY. 


145 


occurred  at  all.  Most  subsequent  investigators  have  more  or  less  fully  confirmed 
their  contentions,  so  that  at  the  present  time  no  one  claims  that  a  distinct  continu- 
ous decidual  membrane  is  formed  in  tubal  pregnancy. 

On  the  other  hand,  it  must  be  distinctly  stated  that  it  is  equally  erroneous  to 
believe  that  a  decidual  reaction  is  always  lacking,  as  it  is  possible  by  careful  study 
to  distinguish  clearly  between  fetal  and  decidual  cells.  In  some  cases  apparently 
no  trace  of  the  latter  can  be  observed,  but  in  many  specimens  they  can  be  found  in 
discrete  patches  in  the  tips  of  some  of  the  folds  of  the  mucosa  in  the  neighborhood 
of  the  ovum.  Furthermore,  careful  study  will  occasionally  enable  one  to  distinguish 
decidual  cells  scattered  between  the  fetal  tissues  at  the  placental  site,  but  in  none 


tJi.^ ,  Tv- '^••>f^fl.,i*#**'^  -  -  -  Syn. 
% '"  '>#yS^'^^'- •  #—  L  C. 


«'  c 


Dec-  f- 


^„^    „  -^-s     oc> 


'LL£*_liS":!,&itt:.JU^^^ 


'L  C. 


Fig.  425. — Section  showing   Attachment  of  Chorion  to  Tube  Wall.     X  90. 
Dec,  Decidual  cells;  L.  C,  Langhans'  cells;  Syn.,  syncytium;  V.,  villi. 

of  my  specimens  have  I  been  able  to  observe  structures  analogous  to  the  decidua 
vera  or  serotina  of  uterine  pregnancy. 

Observations'by  Webster,  Voigt,  Both,  Couvelaire,  Dobbert,  Petersen,  I.ange, 
Kermauner,  myself  and  others  have  proved  the  occurrence  of  decidual  cells  beyond 
all  doubt.  Accordingly,  it  would  seem  that  the  authors  who  deny  their  existence 
take  too  extreme  a  view. 

That  the  tube  is  not  incapable  of  a  decidual  reaction  has  Ukewise  been  demon- 
strated by  finding  characteristic  decidual  cells  in  the  non-pregnant  tube  (Fig.  425). 
Such  observations  have  been  made  by  Webster,  Mandl,  Goebel,  Janot,  Kromer, 
myself  and  others,  and  are  beyond  all  criticism,  as  in  such  cases  there  is  no  possi- 

VOL.  II — 10 


146  EXTRAUTEEINE  PREGNANCY. 

bility  of  confusing  them  with  fetal  cells.  Moreover,  Mandl  and  Lange  have  noted 
a  similar  reaction  in  the  tubes  in  certain  cases  of  uterine  pregnancy,  the  latter  having 
observed  it  in  five  out  of  fifty  specimens. 

From  the  considerations  just  adduced  it  is  apparent  that  while  a  decidual  reac- 
tion may  occur  in  the  tubes  in  tubal  pregnancy,  it  is  not  universal,  and  never  de- 
velops to  the  same  extent  as  in  the  uterus.  This  fact  is  of  interest  not  only  from  a 
scientific  point  of  view,  but  also  has  a  distinctly  practical  bearing,  as  it  would  seem 
to  offer  a  satisfactory  explanation  for  the  invasion  and  destruction  of  the  tube  wall 
by  the  fetal  elements.  In  uterine  pregnancy  such  an  invasion  is  noted  only  in  the 
rare  instances  in  which  there  is  imperfect  development  of  the  decidua,  and  it  would 
therefore  appear  that  one  of  the  main  purposes  of  the  latter  is  to  protect  the  under- 
lying maternal  tissues  against  the  invading  and  corrosive  action  of  the  fetal  elements. 

Decidua  Reflexa. — It  has  already  been  indicated  that  from  the  time  of  Roki- 
tansky  one  set  of  observers  have  held  that  a  definite  decidua  reflexa  is  formed 
just  as  in  uterine  pregnancy,  while  others  have  contended  just  as  strongly  that  it  is 
usually  absent.  As  advocates  of  the  former  view  one  may  mention  Hennig,  Orth- 
mann,  Keller,  Zedel,  Winckel,  Martin,  Couvelaire,  and  Cornil;  while  the  opposite 
view  is  maintained  by  Rokitansky,  Leopold,  Klein,  Abel,  Fraenkel,  Fiith,  Kreisch, 
and  Dobbert.  Is  it  possible  to  reconcile  such  divergent  and  contradictory  state- 
ments ? 

In  view  of  the  generally  scanty  development  of  decidual  tissue  in  tubal  preg- 
nancy, it  would  appear,  a  priori,  improbable  that  a  typical  decidua  reflexa  could  be 
formed.  On  the  other  hand,  all  recent  investigators  who  have  studied  the  early 
stages  of  unruptured  tubal  pregnancy  are  agreed  that  the  ovum  is  separated  from 
the  lumen  of  the  tube  by  a  definite  membrane,  made  up  of  connective  and  mus- 
cular tissue,  and  bounded  on  one  side  by  tubal  epithelium  and  on  the  other  by  fetal 
elements  (Fig.  424). 

In  the  early  days  of  pregnancy  the  nature  of  the  membrane  is  perfectly  clear, 
and  as  it  does  not  contain  decidual  cells,  it  would  be  manifestly  improper  to  describe 
it  as  a  decidua  reflexa.  At  the  same  time,  it  serves  the  same  function  as  that 
structure,  and  accordingly  may  be  designated  as  the  pseudo-reflexa,  or,  better  still, 
as  the  capsular  membrane.  As  the  pregnancy  advances  it  becomes  invaded  by 
fetal  cells,  and  to  the  casual  observer  may  offer  considerable  similarity  to  a  typical 
decidua  reflexa.  Gradually,  however,  under  the  corroding  action  of  the  fetal  cells 
it  undergoes  degenerative  changes,  so  that  it  eventually  becomes  converted  into  a 
layer  of  fibrinous  tissue  without  definite  structure.  In  the  vast  majority  of  cases  it 
soon  ruptures  and  allows  the  growing  ovum  to  escape  into  the  lumen  of  the  tube  as 
a  tubal  abortion.  Occasionally,  however,  this  does  not  occur,  and  in  that  eveut  it 
comes  in  contact  and  eventually  fuses  with  the  mucosa  of  the  opposite  side  of  the 
tube,  which  then  may  become  invaded  by  fetal  elements. 

It  would  accordingly  appear  that  those  authors  who  have  described  a  typical 
decidua  reflexa  have  confounded  it  with  a  capsular  membrane  infiltrated  with  fetal 
cells;  while  those  who  have  denied  its  existence  have  based  their  conclusions  upon 


TUBAL   PREGNANCY. 


147 


the  study  of  specimens  in  which  the  capsular  membrane  had  already  ruptured,  or 
had  become  so  degenerated  that  it  was  impossible  to  distinguish  its  integral  struc- 
ture. 

Placenta. — As  has  been  stated,  the  early  stages  in  the  formation  of  the  pla- 
centa are  identical  in  both  tubal  and  uterine  pregnancy,  and  the  main  factor  which 
influences  its  further  development  in  the  former  is  the  absence  or  imperfect  forma- 
tion of  a  decidua  serotina.  As  a  consequence,  the  only  obstacle  to  the  invasion  of 
the  tube  wall  by  the  fetal  elements  is  the  natural  resistance  of  the  maternal  tissues, 
and  unfortunately  this  is  rarely  able  to  maintain  a  successful  struggle.  Accordingly 
the  tube  wall  in  contact  with  the  ovum  undergoes  degenerative  changes  and  becomes 
in  great  part  converted  into  fibrin,  which  apparently  offers  such  slight  resistance 
that  the  chorionic  villi  and  fetal  cells  invade  the  tube  wall,  open  up  its  blood-vessels, 
and  in  a  short  time  are  to  be  found  just  beneath  the  peritoneum.  It  was  this  con- 
dition which  caused  Werth  in  1887  to  compare  extrauterine  pregnancy  with  a  ma- 
lignant growth. 

In  a  small  proportion  of  cases  the  fetal  structures  penetrate  directly  through  the 


Fig.  426. — Syncytial  Mass  in  Blood-vessel  of  Tube,  far  Removed  from  Placental  Site. 

peritoneal  surface  or  through  the  capsular  membrane,  giving  rise  to  intraperitoneal 
rupture  or  tubal  abortion,  as  the  case  may  be;  although  in  the  vast  majority  of  cases 
early  rupture  is  to  be  attributed  to  the  sudden  opening  up  of  a  large  vessel,  which 
gives  rise  to  an  increase  of  pressure,  which  the  weakened  tube  walls  are  unable  to 
withstand.  Werth  has  quaintly  expressed  the  condition  in  tubal  pregnancy  by 
stating  that  the  ovum,  in  making  its  bed,  digs  its  own  grave. 

The  microscopic  structure  of  the  fetal  portion  of  the  placenta  is  identical  in  both 
tubal  and  uterine  pregnancy,  and  does  not  call  for  extended  description  in  this  place. 
Likewise,  just  as  in  uterine  pregnancy,  but  probably  to  a  greater  extent,  particles 
become  broken  off  from  the  fetal  portion  of  the  placenta— masses  of  Langhans'  cells 
or  syncytium,  or  even  fragments  of  villi — and  are  carried  by  the  veins  to  various 
portions  of  the  body.  This  process,  which  was  designated  by  Veit  as  "deportation, " 
can  be  demonstrated  by  cutting  serial  sections  of  the  tube  at  a  point  far  removed 
from  the  site  of  pregnancy,  and  finding  placental  giant  cells  or  even  fragments  of 
villi  in  the  veins  (Fig.  426). 


148  EXTRAUTERINE  PREGNANCY. 

Veit  has  still  further  extended  his  conception  of  "deportation"  by  applying  it  to 
the  growth  into  venous  channels  of  chorionic  villi,  which  still  retain  their  connection 
with  the  placenta.  He  considers  that  such  a  condition  plays  a  most  important  part 
in  the  production  of  rupture,  as  he  holds  that  the  clogging  of  large  veins  by  villi  may 
so  raise  the  blood-pressure  in  the  intervillous  spaces  that  the  weakened  tube  wall 
necessarily  gives  way. 

It  is  stated  by  Gubb  and  other  writers  that  it  is  not  unusual  for  the  placenta  to 
continue  to  grow  after  the  death  of  the  fetus.  Except  in  the  rare  cases  of  hydatidi- 
form  mole  formation,  I  agree  with  Berry  Hart  that  such  growth  is  out  of  the  question; 
though  it  must  be  admitted  that  occasionally  in  advanced  tubal  pregnancy  hemor- 
rhages into  the  placenta  may  lead  to  an  increase  in  size,  which  might  cause  one  to 
consider  such  a  possibility. 

Structure  of  the  Sac  Wall  in  Tubal  Pregnancy. — In  the  early  stages  of  tubal 
pregnancy  one  finds  a  small  round  or  fusiform  swelling  at  a  given  point  in  the  tube, 
which  in  most  of  the  very  early  cases  which  I  have  examined  was  situated  in  the 
isthmus  of  the  tube,  1  or  2  cm.  from  the  uterus  (Fig,  424).  In  more  advanced  cases 
the  pregnancy  is  usually  situated  in  the  ampulla. 

Microscopic  examination  through  the  sac  in  such  cases  shows  a  slight  hyper- 
trophy of  the  pre-existing  muscle  cells,  but  apparently  no  increase  in  their  number; 
although,  according  to  Werth  and  Dobbert,  this  is  frequently  lacking.  At  the  same 
time  the  tube  wall  is  considerably  thickened,  and  the  muscle  cells  spread  apart  by 
edema.  There  is  also  a  marked  increase  in  vascularity,  the  larger  veins  and  arteries 
being  considerably  hypertrophied,  and  the  smaller  vessels  markedly  engorged, 
especially  in  the  neighborhood  of  the  placental  site. 

In  many  cases  there  is  considerable  free  hemorrhage  into  the  tube  wall  in  the 
neighborhood  of  the  placental  site;  and  at  a  later  period  marked  degenerative 
changes  occur  in  the  neighborhood  of  the  growing  villi,  so  that  eventually  consider- 
able portions  of  the  tube  are  converted  entirely  into  fibrinous  material. 

In  more  advanced  cases  the  walls  of  the  fetal  sac  vary  considerably  in  thickness, 
in  some  places  being  hardly  thicker  than  a  sheet  of  paper,  and  in  others  attaining  a 
thickness  of  several  millimeters.  As  the  pregnancy  advances  the  muscular  constit- 
uents of  the  tube  wall  appear  to  diminish  in  number,  so  that  at  full  term  the  sac 
is  almost  entirely  made  up  of  connective  tissue  which  is  poor  in  cells,  with 
only  here  and  there  a  muscle-fiber.  This  indicates  that  the  muscle  cells  of  the  tube 
usually  do  not  exhibit  the  same  tendency  to  hypertrophy  as  in  the  pregnant  uterus; 
although  occasionally  it  may  be  quite  marked,  as  Pinard  has  reported  a  case  of  ad- 
vanced tubal  pregnancy  in  which  the  fetal  sac  contracted  so  strongly  that  he  believed 
that  he  had  to  deal  with  the  uterus.  It  has  been  erroneously  stated  that  the  presence 
of  muscular  tissue  in  the  sac  wall  will  enable  one  to  distinguish  between  tubal  and 
other  fetal  sacs,  but  a  certain  amount  of  muscular  tissue  can  generally  be  found, 
even  in  broad  ligament  pregnancy.  In  the  majority  of  cases  one  finds  more  or  less 
marked  evidences  of  peritoneal  involvement  on  the  exterior  of  the  tube,  and  in 


TUBAL    PREGNANCY.  149 

some  cases  it  would  appear  that  a  considerable  portion  of  the  thickness  of  the  fetal 
sac  is  of  inflammatory  origin. 

In  complete  tubal  abortion  it  is  essential  that  the  fimbriated  extremity  of  the 
tube  remains  patent,  but  in  the  other  cases  its  condition  varies,  being  sometimes 
closed  and  sometimes  open.  Bland-Sutton  and  Veit  hold  that  its  closure  is  of 
almost  constant  occurrence,  and  is  due  to  the  pregnancy  itself  and  not  to  peritoneal 
involvement.  For  my  part,  I  do  not  believe  that  this  is  a  universal  rule,  as  I  have 
seen  several  cases  of  advanced  tubal  pregnancy  in  which  the  fimbriated  end  was 
patent  and  absolutely  unchanged. 

It  is  also  interesting  to  inquire  as  to  the  relation  of  the  lumen  of  the  tube  to  the 
fetal  sac,  and  it  may  be  stated  that  there  is  no  general  rule  concerning  it.  In  a 
certain  number  of  cases  I  have  been  able  to  trace  it  directly  into  both  poles  of  the 
fetal  sac;  whereas  in  others  it  communicated  with  only  one  pole,  and  in  still  otlier 
cases  serial  sections  showed  that  it  had  become  completely  obliterated  before  either 
pole  was  reached.  I  am  unable  to  account  for  these  differences,  but  it  is  apparent 
that  when  the  lumen  of  the  tube  is  occluded  on  the  distal  side  of  the  sac,  the  chance 
of  rupture  is  markedly  increased  in  event  of  a  sudden  hemorrhage. 

Werth,  in  his  monograph  of  1887,  directed  attention  to  a  peculiar  condition 
of  the  tube  on  the  uterine  side  of  the  fetal  sac,  and  pointed  out  that  its  lumen,  instead 
of  becoming  progressively  larger  as  it  approached  the  sac,  became  converted  into  a 
sieve-like  structure,  the  meshes  of  which  became  smaller  and  smaller,  and  gradually 
disappeared  just  before  reaching  the  sac.  I  have  observed  the  same  condition  in 
one  case,  but  am  unable  to  state  whether  it  was  due  to  antecedent  inflammatory  con- 
ditions, as  in  so-called  follicular  salpingitis,  or  whether  it  was  directly  connected 
with  the  pregnancy. 

Uterine  Decidua. — Since  the  time  of  Boehmer  and  Hunter  it  has  been  generally 
admitted  that  the  uterine  mucosa  is  transformed  into  a  decidua  in  extrauterine  as 
well  as  in  intrauterine  pregnancy.  Its  structure,  however,  was  first  carefully 
studied  by  Ercolani,  and  after  him  by  Leopold,  Conrad  and  Langhans,  Dobbert, 
Tussenbroek,  and  Cazeaux. 

It  is  usually  stated  that  the  uterine  decidua  is  practically  identical  in  structure 
in  both  extrauterine  and  intrauterine  pregnancy,  and  consists  of  the  usual  compact 
and  spongy  layers.  I  am,  however,  inclined  to  agree  with  Dobbert  and  Tussen- 
broek that  it  presents  a  somewhat  different  structure  in  the  former,  for  in  several 
uteri  which  I  have  examined  the  spongy  layer  was  not  so  well  developed  as  in  uterine 
pregnancy,  while  beneath  it  there  was  a  layer  of  varying  thickness  which  presented 
an  almost  normal  appearance.  According  to  Cazeaux,  the  decidual  formation  is 
more  intense  when  the  pregnancy  is  situated  in  the  proximal  portion  of  the  tube. 

The  epithelium  covering  the  decidua  usually  becomes  flattened,  just  as  Klein 
has  described  in  uterine  pregnancy,  and  the  vessels  just  beneath  it  are  markedly 
engorged.  Moreover,  I  am  inclined  to  agree  with  Tussenbroek  that  the  frequent 
occurrence  of  uterine  hemorrhage  in  extrauterine  pregnancy  is  probably  due  to  the 
fact  that  these  engorged  vessels  lie  just  beneath  its  free  surface,  instead  of  being  cov- 


150 


EXTRAUTERINE   PREGNANCY. 


ered  by  the  decidual  reflexa  and  a  layer  of  fetal  cells,  as  is  the  case  in  uterine  preg- 
nancy after  the  first  few  weeks. 

This  decidua  is  generally  cast  off  from  the  uterus  soon  after  the  death  of  the  fetus, 
either  in  to  to  or  in  small  pieces  (Fig.  427),  and  its  discharge  is  usually  considered 
to  possess  marked  diagnostic  significance ;  so  much  so  that  some  writers  in  suspected 
cases  have  recommended  curetting  the  uterus,  and  base  their  diagnosis  upon  the 
presence  or  absence  of  decidual  tissue.  My  own  experience  has  taught  me  that 
this  is  not  necessarily  so  valuable  a  diagnostic  sign  as  is  generally  believed,  for 
in  many  instances  it  may  be  expelled  without  the  knowledge  of  the  patient  and  be- 
come replaced  by  a  normal  mucosa,  so  that  examination  of  the  material  removed  by 
the  curet  would  show  normal  endometrium  and  absolutely  no  sign  of  decidual 

tissue.  Pilliet  has  also  had  a  similar  experi- 
ence, while  Cazeaux  states  that  in  certain 
cases  of  hematosalpinx  the  endometrium  pre- 
sents the  ordinary  lesions  of  chronic  endo- 
metritis, but  no  sign  of  decidual  formation. 

Terminations  of  Tubal  Pregnancy. — 
According  to  Tait,  the  universal  fate  of  tubal 
pregnancy  is  rupture  into  the  peritoneal  cavity 
or  between  the  folds  of  the  broad  ligament. 
More  careful  study,  however,  has  shown  that 
this  statement  is  incorrect,  and  that  the  great 
majority  of  cases  terminate  at  an  early  period 
by  abortion  after  rupture  through  the  capsular 
membrane,  while  in  very  rare  instances  the 
pregnancy  may  develop  to  term  without  rup- 
ture. Examples  of  the  latter  termination 
have  been  reported  by  Saxtorph,  Spiegelberg, 
Chiari,  Gutzwiller,  Emanuel,  Freund,  and 
others,  and  I  have  a  similar  specimen.  In 
the  vast  majority  of  cases,  however,  the  preg- 
nancy is  interrupted  at  a  much  earlier  period,  by  abortion  or  rupture. 

Tubal  Abortion  (Intratuhal  Rupture). — It  was  not  until  1887  that  Werth  directed 
attention  to  the  occurrence  of  tubal  abortion.  Since  then  numerous  investigators 
have  substantiated  his  work,  among  whom  may  be  mentioned  Orthmann,  Sutton, 
and  Prochownick;  so  that  at  present  it  is  regarded  as  the  most  frequent  outcome 
of  tubal  pregnancy,  instead  of  a  pathologic  curiosity. 

The  marked  change  which  has  taken  place  in  this  respect  is  clearly  shown  by 
comparing  the  statistics  of  Schrenk  with  those  of  more  recent  investigators.  In 
1892  he  noted  abortion  only  eight  times  in  610  cases  of  tubal  pregnancy  collected 
from  the  literature;  while  in  289  cases  reported  by  Martin,  Orthmann,  Mandl  and 
Schmidt,  Fehling,  and  Glitsch,  78  per  cent,  ended  by  abortion  and  only  22  per  cent, 
by  rupture.     According  to  Martin,  "this  process  is  the  general  rule,  spontaneous 


Fig.  427. — ^Uterine  Decidua  from  a  Case  of 
Extrauterine  Pregnancy  (Zweifel). 


TUBAL    PREGNANCY.  151 

rupture  occurring  only  in  those  cases  in  which  closure  of  the  abdominal  end  of  the 
tube  precludes  the  possibility  of  abortion;  or  where  the  ovum  being  inserted  in  a 
hernia  of  the  mucosa,  burrows  directly  through  its  wall. " 

All  recent  writers  report  a  similar  experience,  although  its  frequency  depends  in 
great  part  upon  the  original  site  of  implantation  of  the  ovum.  When  in  the  ampulla, 
abortion  is  the  general  rule;  while  rupture  into  the  peritoneal  cavity  is  the  usual 
termination  of  isthmic  pregnancy — Couvelaire,  Werth,  Kermauner.  This  differ- 
ence must  be  attributed  to  the  fact  that  in  the  ampulla  the  tubal  lumen  is  sufficiently 
patulous  to  permit  a  certain  degree  of  expansion  of  the  fetal  sac,  while  in  the  isthmus 
the  lumen  is  so  small  that  this  is  impossible.  Accordingly,  growth  can  occur 
only  toward  the  periphery,  and  therefore  early  rupture  is  the  general  rule. 

Tubal  abortion  is  practically  always  the  result  of  rupture  through  the  capsular 
membrane  or  pseudo-reflexa,  and  therefore  does  not  differ  materially  ffom  intra- 
peritoneal rupture,  except  in  the  fact  that  in  the  one  case  the  hemorrhage  and  ex- 
trusion of  the  ovum  occurs  into  the  lumen  of  the  tube,  while  in  the  other  it  takes 
place  into  the  peritoneal  cavity.  Accordingly,  the  term  abortion  is  not  very  happilv 
chosen,  and,  as  suggested  by  Berkeley  and  Bonney,  the  usual  terminations  of  tubal 
pregnancy  could  well  be  designated  as  intra-tubal  and  extra-tubal  rupture,  respec- 
tively. 

Intratubal  rupture  or  abortion  is  brought  about  either  by  the  direct  perforation 
of  the  capsular  membrane  by  fetal  elements,  or  by  the  weakened  and  thinned  out 
membrane  yielding  to  a  sudden  increase  in  the  interovular  pressure.  The  latter 
may  result  from  the  sudden  opening  up  of  a  large  vessel  by  the  invading  fetal  ele- 
ments, by  the  clogging  of  large  veins  by  chorionic  villi  (Veit,  Pfannenstiel),  or  by 
the  process  described  by  Fellner  as  autothrombosis,  in  which  the  lumina  of  large 
venous  channels  have  become  occluded  by  decidual  cells,  which  originated  in 
their  walls  or  invaded  them  from  the  outside. 

The  immediate  consequence  of  the  hemorrhage  is  a  loosening  of  the  connections 
between  the  tube  wall  and  the  ovum,  and  its  complete  or  partial  separation  from  its 
bed.  If  the  separation  is  complete,  the  entire  ovum  is  expelled  into  the  lumen  of 
the  tube,  and  gradually  forced  by  the  hemorrhage  toward  its  fimbriated  extremity, 
through  which  it  may  ultimately  be  extruded  into  the  peritoneal  cavity  (Fig.  428). 
Occasionally  the  ovum  has  been  observed  in  the  act  of  passing  through  the  fimbri- 
ated extremity,  and  I  have  in  my  possession  two  specimens  in  which  the  fetus  sur- 
rounded by  its  membranes  is  protruding  through  its  dilated  opening.  On  the  other 
hand,  if  the  separation  is  only  partial,  the  ovum  will  remain  in  sihi,  while  the 
hemorrhage  continues. 

Accordingly  we  are  obliged  to  distinguish,  just  as  in  the  uterus,  between  com- 
plete and  incomplete  abortions,  the  latter  occurring  far  more  frequently;  AYormser, 
and  Mandl  and  Schmidt,  having  observed  the  complete  variety  in  only  2  out  of  20, 
and  4  out  of  50  cases  of  tubal  abortion,  respectively. 

According  to  Werth  and  Veit,  the  complete  extrusion  of  the  ovum  from  the  tul^e 
is  brought  about  by  muscular  contractions,  just  as  in  uterine  abortion;  but  Martin 


152 


EXTRAUTERINE    PREGNANCY. 


and  Orthmann  believe  that  the  tube  wall  plays  only  a  passive  part,  the  expulsion 
being  effected  by  the  vis  a  tergo  exerted  by  the  blood,  which  collects  behind  the  ovum 
and  gradually  forces  it  through  the  tube.  Prochownik,  on  the  other  hand,  takes  a 
middle  ground,  and  supposes  that  while  hemorrhage  is  the  prime  factor,  it  may  be 
aided  by  the  contractions  of  the  tube  on  the  uterine  side  of  the  sac. 

The  probability  of  complete  tubal  abortion  is  markedly  increased  the  nearer 


b.c. 


--t-.y 


Fig.  428. — Early  Tubal  Abortion;  Ovum  in  Lumen  of  Tube.   X  6. 
b.  c,  Blood-clot;  v.,  villi. 


the  ovum  is  implanted  to  the  fimbriated  extremity,  as  under  such  circumstances  it 
has  a  shorter  distance  to  traverse.  Cullingworth  has  pointed  out  that  the  tube 
occasionally  retracts  very  rapidly  after  expelling  the  ovum,  so  that  casual  examina- 
tion a  few  hours  later  would  fail  to  reveal  through  which  tube  it  passed. 

Occasionally  abortion  and  rupture  may  occur  in  the  same  tube,  particularly 
when  some  obstacle  is  opposed  to  the  onward  passage  of  the  ovum,  such  as  a 
twist  or  partial  closure  of  the  fimbriated  extremity;  as  under  such  circumstances 


TUBAL    PREGNANCY. 


153 


T.W.-  - 


-Ov. 


-  -B.C. 


the   blood  which  collects  between  the  ovum  and  the  uterus  is  subjected  to  such 
pressure  that  the  weakened  walls  of  the  tube  give  way. 

\\Tien  the  ovum  is  completely  separated  from  the  tube  wall,  and  the  hemorrhage 
following  it  is  profuse,  it  is  usually  rapidly  extruded ;  but  when  it  is  only  partially 
separated,  and  the  hemorrhage  is  moderate  in  amount,  the  ovum  may  increase 
markedly  in  size  as  the  result  of  infiltration  with  blood,  and  become  converted 
into  a  structure  analogous  to  the  bloody  or  fleshy  moles  observed  in  uterine  abor- 
tions. Under  such  circumstances  the  hemorrhage  continues  as  long  as  the  mole 
remains  within  the  tube,  and  slowly  trickles  from  its  fimbriated  extremity,  gi^^ng 
rise  to  a  pelvic  hematocele  instead  of  free  hemorrhage  into  the  peritoneal  cavity. 

In  a  small  number  of  cases  the  blood 
in  the  tube  does  not  coagulate,  but  re- 
mains more  or  less  fluid,  giving  rise  to  a 
hematosalpinx.  At  the  present  time 
it  is  generally  believed  that  the  vast 
majority  of  such  cases  originate  from 
tubal  pregnancy,  as  Cullingworth  dem- 
onstrated such  an  origin  in  14  out  of 
the  17  cases  which  he  observed. 

After  incomplete  abortion  small 
portions  of  placental  tissue  frequently 
remain  attached  to  the  tube  wall. 
These  become  surrounded  by  larger 
or  smaller  quantities  of  fibrin,  and  a 
polypus  results,  just  as  frequently 
occurs  after  incomplete  uterine  abor- 
tion. Attention  was  first  directed  to 
this  condition  by  Sutton,  whose  ob- 
servations have  been  confirmed  by 
Frankel,  Fehling,  and  other  observers. 

Rupture  into  the  Peritoneal  Cavity. 
— Extratubal  rupture  does  not  occur 
anything   like   so   frequently   as   Tait 

believed,  as  scarcely  one-quarter  of  the  cases  of  tubal  pregnancy  so  terminate  during 
the  first  twelve  weeks. 

When  the  pregnancy  is  situated  in  the  ampulla,  this  termination  occurs  far  less 
frequently  than  abortion ;  whereas  in  the  isthmic  variety  it  is  the  general  rule.  INIore- 
over,  it  occurs  at  a  much  earlier  period  in  the  latter  variety,  and  occasionally  even 
before  the  patient  is  aware  that  she  is  pregnant.  This  tendency  to  early  rupture 
was  particularly  emphasized  by  Bouilly,  whose  experience  has  been  confirmed 
by  Werth,  Couvelaire,  Kermauner,  and  most  recent  writers.  Its  explanation  is  to 
be  found  in  the  fact  that  the  lumen  of  the  proximal  portion  of  the  tube  is  too  small 
to  permit  of  any  expansion  on  the  part  of  the  ovum,  which  consequently  can  find 


Fig.  429. — Section  Through  Tubal  Mole.     X  1. 

B.C.,  Blood-clot;    Ov.,  ovum;    T.,  uterine  end  of  tube; 

T.W.,  tube  wall. 


154  EXTRAUTERINE  PREGNANCY. 

room  for  growth  only  by  burrowing  deeply  into  the  muscularis,  which  soon  yields 
to  the -invading  \'illi. 

Rupture  is  likewise  the  usual  termination  when  the  pregnancy  is  situated  in  the 
interstitial  portion  of  the  tube,  but  occurs  at  later  period  than  in  the  other  varieties 
of  tubal  pregnancy — rarely  before,  and  not  infrequently  considerably  later  than, 
the  fourth  month.  This  difference  must  be  attributed  to  the  fact  that  this  part 
of  the  tube  is  surrounded  by  uterine  musculature,  which  reacts  promptly  to  the 
stimulation  of  pregnancy  and  offers  a  greater  resistance  to  the  invading  fetal  struc- 
tures than  the  tube  wall. 

The  direct  cause  of  rupture  in  any  part  of  the  tube  may  be  violence,  such 
as  a  vaginal  examination,  coitus,  a  fall,  or  even  mere  overexertion;  though  in 
the  vast  majority  of  cases  it  occurs  spontaneously.  In  either  event  the  underl}dng 
factor  is  the  intramural  embedding  of  the  ovum,  and  the  constant  invasion  and  weak- 
ening of  the  M'all  by  its  ectodermal  elements,  and  later  by  the  growing  chorionic 

vim. 

The  evidence  at  present  available  seems  to  indicate,  except  when  the  pregnancy 
is  in  the  extreme  proximal  end  of  the  tube,  that  direct  perforation  by  fetal  elements 
is  less  usual  than  the  yielding  of  the  weakened  tube  wall  to  a  sudden  increase  of 
pressure  in  the  intra  villous  spaces,  following  the  sudden  opening  up  of  a  large 
vessel,  or  the  clogging  of  venous  channels  by  chorionic  villi.  If  rupture  occurs  in 
this  way  in  an  otherwise  normal  tube,  it  is  apparent  that  it  will  be  likely  to  occur  at 
a  much  earlier  period  if  the  ovum  be  arrested  in  a  diverticulum  from  the  lumen  of 
the  tube,  as  under  such  circumstances  it  will  have  only  a  part  of  the  tube  wall  to 
penetrate,  instead  of  its  entire  thickness.  Occasionally,  secondary  rupture  may 
occur  in  a  tube  the  seat  of  a  primary  abortion,  although  this  is  possible  only  when 
the  fimbriated  end  is  occluded. 

Rupture  usually  occurs  in  the  neighborhood  of  the  placental  site,  and  either  into 
the  peritoneal  ca^nty  or  between  the  folds  of  the  broad  ligament,  depending  upon 
the  original  site  of  the  ovum.  The  terminations  of  the  two  conditions  differ  so 
markedly  that  it  will  be  necessary  to  consider  them  separately. 

When  it  takes  place  into  the  peritoneal  cavity,  the  entire  ovum  may  be  extruded 
from  the  tube,  but,  if  the  rent  be  small,  profuse  hemorrhage  may  occur  without  its 
escape.  In  either  event  the  patient  immediately  shows  signs  of  collapse,  which 
may  rapidly  end  in  death.  If  the  hemorrhage  does  not  lead  to  a  fatal  termination, 
the  effect  of  rupture  varies  according  to  the  amount  of  damage  sustained  by  the 
ovum.  If  expelled  intact  into  the  peritoneal  cavity,  its  death  is  inevitable;  and  un- 
less advanced  beyond  the  third  month  it  will  be  rapidly  absorbed,  as  was  shown  by 
Leopold's  experiments  upon  animals.  It  is  still  thought  by  many  that  under 
such  circumstances  the  placenta  may  become  attached  to  any  portion  of  the  peri- 
toneal cavity,  and  there  establish  vascular  connections,  which  will  render  further 
development  possible.  I  do  not  believe  that  this  can  occur,  as  it  is  highly  improbable 
that  such  connections  could  be  established  before  the  ovum  had  become  irreparably 
damaged,  not  to  speak  of  the  negative  evidence  afforded  by  Leopold's  experiments. 


TUBAL    PREGNANCY, 


155 


On  the  other  hand,  if  only  the  fetus  escapes  at  the  time  of  rupture,  the  effect  upon 
the  pregnancy  will  vary  according  to  the  amount  of  damage  sustained  by  the  pla- 
centa. If  much  damaged,  death  of  the  fetus  and  termination  of  the  pregnancy  are 
inevitable;  but  if  the  greater  portion  of  the  placenta  still  retains  its  attachment  to 
the  tube,  further  development  is  possible,  and  the  fetus  may  go  on  to  full  term,  giving 
rise  to  a  so-called  secondary  abdominal  pregnancy.  In  such  cases  the  tube  may 
close  down  upon  the  placenta  and  form  a  sac  in  which  it  remains  during  the  rest  of 
the  pregnancy;  or  a  portion  of  the  placenta  may  remain  attached  to  the  tube  wall, 
while  its  growing  periphery  extends  beyond  it  and  establishes  connection  with  the 
surrounding  pelvic  organs.  Under  such  circumstances  one  may  find  the  placenta 
attached  partly  to  the  tube  and  partly  to  the  uterus,  pelvic  floor,  rectum,  or  even 
the  intestines. 

I  do  not  believe,  however,  that  the  placenta  can  become  directly  attached  to 
organs  far  removed  from  the  pelvic  cavity,  such  as  the  stomach  and  diaphragm,  for 
instance;   and  when  such  conditions  are  observed,  I  consider  that  one  has  to  deal 


Fig,  430. — Ruptured  Ampullar  Pregnancy. 
Am.,  Amnion;   O,  ovary;   P,  placenta;  T,  uterine  end  of  tube. 


with  a  broad  ligament  pregnancy,  in  which  the  placenta  is  situated  upon  the  upper 
portion  of  the  fetal  sac,  which  has  become  adherent  to  the  organ  in  question. 

Most  authorities  believe  that  further  growth  of  the  fetus  is  impossible,  unless  it 
is  surrounded  by  the  amnion;  though  several  observers,  notably  Both,  have  reported 
exceptional  cases  in  which  a  full-term  fetus  lay  perfectly  free  in  the  peritoneal  cavity, 
and  all  that  was  left  of  its  membranes  was  found  in  the  tubal  sac. 

In  this  connection  may  be  mentioned  a  most  interesting  case  reported  by  Leopold, 
in  which  the  pregnant  uterus  had  ruptured  at  about  the  fourth  month,  allowing  the 
fetus  and  its  membranes  to  escape  into  the  peritoneal  cavity  through  a  rent  in  its 
posterior  wall.  At  the  operation  the  rupture  was  found  to  have  healed  completely 
except  for  a  small  opening  through  which  the  umbilical  cord  passed  into  the  uterine 
cavity,  where  the  placenta  was  normally  attached.  A  similar  case  has  also  been 
reported  by  Henrotin. 

Some  years  ago  Webster  reported  a  case  of  full-term  extrauterine  pregnancy 
which  clearly  showed  the  changes  which  may  occasionally  follow  rupture.     At  oper- 


156  EXTRAUTERINE  PREGNANCY. 

ation  the  child  lay  in  a  thin-walled  sac  behind  the  omentum,  while  the  placenta  was 
still  within  the  tube.  After  carefully  studying  frozen  sections  he  was  unable  to 
demonstrate  that  the  gestation  sac  consisted  of  two  parts :  a  lower,  composed  of  the 
tube  in  which  the  placenta  was  inserted,  and  an  upper,  in  which  the  fetus  lay  and 
which  was  made  up  of  amnion,  newly  formed  connective  tissue,  and  peritoneum. 
He  designated  the  condition  as  tubo-peritoneal  gestation,  and  supposed  that  it  re- 
sulted from  the  early  rupture  of  a  tubal  pregnancy,  with  the  escape  into  the  peri- 
toneal cavity  of  the  fetus  surrounded  by  its  amnion,  and  that  the  latter  gradually 
became  converted  into  the  wall  of  the  upper  portion  of  the  sac. 

Rupture  into  Broad  Ligament. — In  a  small  proportion  of  cases  rupture  may 
occur  at  a  portion  of  the  tube  uncovered  by  peritoneum,  so  that  its  contents  and 
the  subsequent  hemorrhage  are  extruded  between  the  folds  of  the  broad  ligament 
instead  of  into  the  peritoneal  cavity. 

Generally  speaking,  this  is  the  most  favorable  variety  of  extratubal  rupture,  and 
usually  terminates  by  the  death  of  the  ovum  and  the  formation  of  a  broad  Hgament 
hematoma,  or  exceptionally  by  the  further  development  of  the  pregnancy  between 
the  folds  of  the  broad  ligament.  When  the  latter  occurs,  it  is  apparent  that  the  pla- 
centa could  not  have  been  completely  detached  from  its  tubal  attachment  at  the  time 
of  rupture.  In  the  exceptional  instances  in  which  it  is  situated  opposite  the  point 
of  rupture,  it  gradually  becomes  displaced  upward  as  the  pregnancy  advances,  and 
comes  to  lie  above  the  fetus ;  while  in  the  more  usual  cases  it  remains  partly  attached 
to  the  tube  and  gradually  extends  downward  between  the  folds  of  the  broad  ligament, 
and  forms  vascular  connections  with  the  pelvic  connective  tissue. 

When  the  pregnancy  continues  under  such  circumstances,  the  fetal  sac  lies  en- 
tirely outside  of  the  peritoneal  cavity,  and  as  it  increases  in  size  the  peritoneum  is 
dissected  up  from  the  pelvic  walls,  so  that  the  condition- is  designated  as  extraperi- 
toneal pregnancy.  Occasionally  the  broad  ligament  sac  may  rupture  at  a  later 
period,  and  the  child  be  extruded  into  the  peritoneal  cavity,  thus  giving  rise  to  a 
secondary  abdominal  pregnancy. 

According  to  Webster,  the  first  case  of  broad  ligament  pregnancy  was  observed 
by  Bergeret.  One  of  the  earliest  cases  of  this  character  was  described  by  Loschge 
in  1818,  but  the  first  important  contribution  was  made  by  Dezeimeris  in  1836,  who 
described  the  condition  as  " subperitoneo-pelvic  pregnancy,"  but  was  unable  to  ex- 
plain satisfactorily  how  the  ovum  made  its  way  into  the  broad  ligament. 

The  importance  of  this  termination  of  tubal  pregnancy  was  particularly  empha- 
sized by  Tait,  who  believed  that  it  was  only  under  such  circumstances  that  the  fetus 
could  go  on  to  maturity.  In  view  of  what  has  been  said,  however,  concerning  un- 
ruptured full-term  tubal  pregnancy,  it  is  evident  that  his  statements  were  based  upon 
imperfect  information.  Werth,  in  1887,  likewise  directed  attention  to  this  condition, 
and  collected  16  cases  from  the  literature,  though  in  his  section  upon  extrauterine 
pregnancy  in  Winckel's  "Handbuch  der  Geburtshiilfe,"  he  states  that  he  has  had  no 
personal  experience  with  it.  Hart  and  Carter  published  a  series  of  frozen  sections 
from  a  case  of  this  character,  which  had  progressed  to  full  term;  and  the  former,  in 


TUBAL    PREGNANCY.  157 

a  number  of  subsequent  publications,  has  added  materially  to  our  knowledge  con- 
cerning the  condition.  He  showed  that  the  term  "  sub-peritoneo-pelvic "  is  not 
applicable  after  the  pregnancy  has  advanced  beyond  the  first  four  or  five  months, 
when  it  should  more  properly  be  designated  as  "  sub-peri toneo-abdominal." 

I  am  confident  that  the  frequency  with  which  rupture  occurs  into  the  broad  liga- 
ment has  been  overestimated,  as  I  have  observed  it  only  once,  and  my  experience 
is  borne  out  by  the  statistics  of  several  recent  observers.  Thus  it  was  noted  only  4 
times  in  276  cases  of  tubal  pregnancy  reported  by  Mandl  and  Schmidt,  Kiistner  and 
Fehling;  and  Kiistner  suggests  that  a  considerable  number  of  cases  which  have  been 
so  interpreted  were  in  reality  due  to  the  formation  of  intimate  adhesions  between  the 
tubal  sac  and  the  posterior  surface  of  the  broad  ligament. 

Owing  to  the  upward  displacement  of  the  peritoneum,  and  the  consequent 
denudation  of  the  pelvic  organs,  broad  ligament  pregnancies  are  brought  into  more 
intimate  relations  with  the  rectum  and  bladder  than  other  varieties  of  extrauterine 
pregnancy,  and  accordingly  are  more  prone  to  infection  by  intestinal  bacteria; 
and  after  suppuration  are  liable  to  perforate  either  into  the  rectum  or  bladder, 
Winckel  having  shown  that  at  least  six  out  of  the  twelve  cases  of  perforation  into 
the  bladder  which  he  collected  from  the  literature  had  resulted  from  this  condition. 

The  terms  "  tuho-uterine"  and  "tuho-ahdominar'  pregnancy  are  sometimes 
applied  to  cases  in  which  a  primary  tubal  pregnancy  develops  partially  into  the 
uterine  or  peritoneal  cavity,  as  the  case  may  be.  The  first  variety  results  from  a 
pregnancy  in  the  interstitial  portion  of  the  tube,  and  probably  a  certain  number  of 
cases  of  supposed  extrauterine  pregnancy  which  have  terminated  by  spontaneous 
labor  were  of  this  character. 

In  tubo-abdominal  pregnancy,  on  the  other  hand,  the  ovum  is  primarily  inserted 
in  the  neighborhood  of  the  fimbriated  extremity,  and  gradually  protrudes  from  it 
into  the  peritoneal  cavity.  Under  such  circumstances  the  protruding  part  of  the 
fetal  sac  rapidly  forms  adhesions  with  surrounding  organs,  which  at  operation 
frequently  offer  serious  complications.  Neither  of  these  conditions  is  very  frequent, 
and  does  not  deserve  to  be  classified  separately,  as  they  differ  from  the  usual  forms 
of  tubal  pregnancy  only  in  the  fact  that  they  have  developed  at  unusual  posi- 
tions. 

The  term  "  tubo-ovarian"  pregnancy  is  applied  to  cases  in  which  the  fetal  sac  is 
composed  partly  of  tubal  and  partly  of  ovarian  tissue.  Such  cases  owe  their  origin 
to  the  development  of  an  ovum  in  a  tubo-ovarian  cyst,  or  in  a  tube  whose  fim- 
briated epd  was  adherent  to  the  ovary  at  the  time  of  fertilization,  and  are  either 
primarily  tubal  or  ovarian,  and  owe  their  peculiar  character  simply  to  accidental 
circumstances. 

VuUiet  is  credited  with  being  the  first  to  describe  such  a  condition,  and  since 
then  not  a  few  observers  have  reported  similar  cases,  though  they  are  not  of  frequent 
occurrence.  Paltauf  described  a  most  interesting  specimen,  in  which  double  tubo- 
ovarian  cysts  communicated  with  one  another.  Pregnancy  occurred  in  the  left 
cyst,  and  at  autopsy  a  sound  could  be  passed  from  the  left  cornu  of  the  uterus, 


158  EXTRAUTERINE  PREGNANCY. 

through  both  ovarian  cysts,  and  back  into  the  uterine  cavity  through  the  right  tube. 
Ashby  has  reported  a  typical  case  of  tubo-ovarian  pregnancy,  which  was  carefully 
examined  by  Dr.  Welch;  and  Leopold  has  described  in  detail  six  cases  of  his  own. 
It  is  likewise  possible,  as  ]Mandl  and  Schmidt  have  pointed  out,  that  not  a  few 
of  the  cases  which  have  been  described  as  tubo-ovarian  are  really  nothing  but  tubal 
pregnancies  with  a  solitary  hematocele  developed  about  the  fimbriated  end  of  the 
tube,  and  adherent  to  the  ovary. 


ABDOMINAL  PREGNANCY. 

Until  comparatively  recently  the  occurrence  of  abdominal  pregnancy  was  uni- 
versally admitted,  and  in  Hecker's  statistics  it  was  reported  twice  as  frequently  as 
the  tubal  form.  As,  however,  the  specimens  obtained  at  operation  and  autopsy 
were  subjected  to  more  careful  study,  it  gradually  became  established  that  the 
majority  of  such  cases  were  not  primarily  abdominal,  but  had  resulted  from  rup- 
tured tubal  pregnancy.  Finally  doubt  began  to  be  cast  upon  the  existence  of  the 
primary  variety,  and  at  the  present  time  most  authors  are  extremely  skeptical  as  to 
its  occurrence,  though  they  admit  its  theoretic  possibihty. 

As  far  as  I  can  learn,  Pfannenstiel  is  the  only  recent  writer  who  does  not  share 
the  general  skepticism.  On  the  other  hand,  Bland-Sutton  positively  denies  its 
occurrence,  and  holds  that  all  specimens  which  have  been  described  as  such  have 
been  imperfecdy  studied.  ^Moreover,  he  contends  that  it  is  not  observed  in  the 
lower  animals,  and  states  that  the  not  infrequent  finding  of  fetal  sacs  in  the 
abdominal  cavity  is  to  be  attributed  to  the  rupture  of  a  uterine  horn  with  the  ex- 
trusion of  one  or  more  embryos  into  the  abdomen.  This  he  considers  is  not  a  very 
rare  accident,  which  in  many  instances  does  not  lead  to  death. 

Considerable  light  has  been  thrown  upon  the  subject  by  the  work  of  Zweifel, 
Martin,  Voigt,  Leopold,  Werth,  and  others,  who  have  conclusively  demonstrated 
that  the  ferdlized  ovum  may  become  implanted  upon  the  fimbria  ovarica — the 
tongue-like  process  extending  from  the  fimbriated  end  of  the  tube  to  the  ovary. 
These  invesdgators  have  pointed  out  that  only  the  most  careful  study  prevented 
them  from  confounding  the  cases  in  question  ^dth  primary  abdominal  pregnancies; 
but  in  all  of  them  thorough  microscopic  examination  showed  the  presence,  at  some 
point  on  the  sac  wall,  of  a  structure  covered  by  cylindric  epithelium,  which  they 
identified  as  the  unchanged  portion  of  the  ovarian  fimbria. 

In  such  cases  it  is  apparent  that  as  the  pregnancy  develops  the  surface  to  which 
the  ovum  was  primarily  attached  will  be  far  too  small  to  accommodate  the  placenta, 
and  accordingly  its  margins  soon  extend  beyond  the  primary  site  of  implantation, 
and  becoming  attached  to  surrounding  organs,  give  the  impression  that  it  had 
been  implanted  primarily  upon  the  peritoneum. 

Zweifel,  when  he  first  examined  his  specimen,  considered  that  it  was  undoubtedly 
a  primary  abdominal  pregnancy,  and  only  recognized  its  true  nature  after  most 
careful  studv.     Walker,  in  1887,  described  a  case  which  has  long  figured  as  an  un- 


FATE  OF  THE  FETUS  IN  EXTRAUTERINE  PREGNANCY.  159 

assailable  example  of  this  condition;  but,  as  Zweifel  has  pointed  out,  his  accurate 
microscopic  description  leaves  very  little  doubt  that  it  was  likewise  a  pregnancy 
upon  a  fimbria  ovarica. 

I,  therefore,  do  not  believe  that  a  single  case  has  thus  far  been  reported  which 
affords  indisputable  proof  of  the  primary  occurrence  of  abdominal  pregnancy; 
but  at  the  same  time  one  must  admit  such  a  possibility,  especially  in  view^  of  the 
fact  that  Walker,  Zweifel,  and  Voigt  have  demonstrated  the  development  of  decid- 
ual cells  in  the  subperitoneal  tissue,  and  also  that  Schmorl  has  shown  that  decidual 
nodules  appear  upon  the  pelvic  peritoneum  in  the  course  of  normal  uterine  preg- 
nancy. 

FATE  OF  THE  FETUS  IN  EXTRAUTERINE  PREGNANCY. 

I  have  already  pointed  out  that  absorption  is  the  universal  fate  of  small  embryos 
which  are  extruded  into  the  peritoneal  cavity,  unless  the  placenta  remains  firmly 
attached  to  the  tube.  This  is  clearly  demonstrated  in  some  cases  by  our  inability 
to  find  a  trace  of  the  fetus  in  the  blood  which  fills  the  abdominal  cavity  after  rup- 
ture. It  is  likewise  certain  that  small  embryos  are  frequently  absorbed  while  still 
in  the  tube;  as  one  often  finds  upon  opening  early  gestation  sacs  that  the  fetus  is 
represented  by  a  formless  mass  of  tissue  attached  to  the  umbilical  cord,  while  in 
other  cases  a  short  portion  of  the  cord  hanging  free  in  the  amniotic  cavity  is  the  only 
indication  of  its  previous  existence. 

When  the  fetus,  however,  has  attained  a  certain  size,  it  cannot  be  absorbed  in 
this  manner,  and  one  accordingly  has  to  consider  the  changes  which  it  may  undergo, 
whether  it  remains  in  the  gestation  sac  or  lies  free  in  the  abdominal  cavity.  Gener- 
ally speaking,  these  may  be:  mummification,  skeletization,  lithopedion  formation, 
suppuration,  and  adipocere  formation. 

In  mummification  the  fluid  portions  of  the  fetus  are  gradually  absorbed  and  its 
internal  organs  converted  into  a  soft,  pulpy  mass  which  is  gradually  absorbed,  so 
that  eventually  nothing  is  left  except  the  skeleton,  whose  bones  are  held  together 
by  a  dry  and  shriveled  skin. 

If  infection  does  not  occur,  the  mummified  fetus  or  the  membranes  surrounding 
it,  or  both,  become  covered  by  a  coating  of  calcareous  material,  and  a  structure 
results  to  which  the  name  "lithopedion"  is  generally  applied. 

One  of  the  earliest  recorded  cases  of  this  character  is  the  so-called  lithopedion 
of  Sens  (Lithopsedion  Senonensis),  which  was  removed  from  a  woman  in  the  town 
of  Sens  in  1601,  and  has  become  immortal  among  English-speaking  people  by  its 
misuse  in  "Tristram  Shandy."  Likewise,  one  of  the  most  interesting  specimens  of 
lithopedion  on  record  was  obtained  at  Leinzell  in  1720,  at  the  autopsy  upon  a 
seventy-four-year-old  woman,  who  had  carried  it  within  her  for  forty-eight  years, 
during  which  time  she  had  several  children.  This  has  been  described  by  several 
writers,  but  particularly  by  Kieser  in  1854,  who  collected  most  of  the  cases  which 
had  been  reported  up  to  that  time.     The  condition  was  also  exhaustively  considered 


160  EXTRAUTERINE  PREGNANCY. 

by  Albers  in  1861,  who  collected  ten  cases  from  the  literature,  eight  of  which  had 
been  retained  by  their  mothers  for  twenty-five  years  or  more. 

The  most  valuable  monograph  upon  the  subject  we  owe  to  Kiichenmeister,  who 
after  carefully  reviewing  the  literature  and  studying  several  cases  of  his  own,  divided 
lithopedia  into  three  classes:  (1)  In  which  the  calcification  is  limited  to  the  fetal 
membranes  (litho-kelyphos) ;  (2)  both  fetus  and  membranes  partially  calcified 
(litho-kelyphopedion) ;  and  (3)  in  which  the  calcification  is  limited  entirely  to  the 
fetus  (lithopedion). 

Lithopedion  formation  is  comparatively  rare,  and  is  generally  regarded  as  the 
most  favorable  outcome  in  advanced  cases  of  extrauterine  pregnancy,  as  the  cal- 
cified fetus  may  be  carried  for  years  as  a  harmless  foreign  body,  and  do  no  harm 
except  at  labor,  when  it  may  give  rise  to  partial  or  complete  obstruction  of  the  pel- 
vis. I  have  been  able  to  collect  from  the  literature  a  number  of  cases  in  which  a 
lithopedion  had  been  carried  for  fifty  years  or  more,  and  over  thirty  cases  in  which 
a  period  of  twenty-five  or  thirty  years  elapsed  between  the  pregnancy  and  the  re- 
moval of  the  specimen  at  autopsy  or  operation. 

In  a  considerable  number  of  cases  in  which  the  dead  product  of  conception  re- 
mains within  the  mother,  suppuration  of  the  sac  occurs  and  gradually  spreads  to 
the  fetus  and  eventually  leads  to  the  liquefaction  of  all  its  parts  except  the  skeleton. 
As  the  process  advances,  adhesions  are  formed  with  the  various  organs,  and  an 
abscess  forms,  which  eventually  perforates  at  the  point  of  least  resistance;  and  if 
the  patient  does  not  succumb  to  septic  intoxication,  portions  of  the  skeleton  may  be 
extruded  through  the  abdominal  walls,  or  into  the  intestines,  bladder,  or  vagina. 
As  has  already  been  indicated,  this  termination  occurs  with  especial  frequency  in  broad 
ligament  pregnancy,  on  account  of  the  proximity  to  the  rectum  and  the  liability  of 
infection  by  intestinal  bacteria. 

In  exceptional  instances  the  tissues  of  the  fetus  may  become  converted  into  a 
yellowish,  greasy  mass,  to  which  the  term  "adipocere"  is  applied.  The  fatty 
material  is  supposed  to  be  an  ammoniacal  soap,  but  no  one  has  as  yet  advanced  a 
satisfactory  explanation  for  its  formation. 


DISEASES  OF  THE  OVUM  IN  EXTRAUTERINE  PREGNANCY. 

The  formation  of  typical  blood  or  fleshy  moles  and  placental  polypi  after  tubal 
abortion  has -already  been  mentioned,  and  it  must  be  admitted  in  a  general  way 
that  the  ectopic  ovum  is  subject  to  the  same  diseases  and  abnormalities  as  in  nor- 
mal pregnancy.  In  this  connection  it  is  interesting  to  note  that  Schauta,  Wertheim, 
and  Micholitsch  have  described  tubal  ova,  which  had  become  converted  into  hema- 
toma moles — the  tuberous  subchorial  hematoma  of  the  decidua  of  Breus.  More- 
over, it  would  appear  likely  that  a  similar  condition  may  develop  in  ovarian  preg- 
nancies, which  terminate  in  the  death  of  the  fetus  without  rupture. 

The  occurrence  of  hydatidiform  moles  has  been  reported  by  Otto,  Reckling- 
hausen, Wenzel,  Matwejew  and  Sykow,  and  others,  and  it  would  appear  that  the 


SYMPTOMS.  161 

condition  does  not  differ  materially  from  that  observed  in  the  uterus.  Chorio- 
epithelioma  likewise  occurs  after  tubal  pregnancy,  and  ten  additional  cases  have 
been  reported  since  Ahlfeld  and  Marchand  first  described  it.  Those  interested 
will  find  the  complete  literature  upon  the  subject  up  to  1905  in  the  monograph  of 
Risel. 

When  the  comparative  infrequency  of  extrauterine  pregnancy  is  taken  into 
consideration,  it  would  appear  to  be  followed  quite  as  often  by  chorio-epithelioma 
as  uterine  gestation.  Moreover,  when  the  fact  is  recalled  that  at  least  one-half  of 
such  cases  have  been  preceded  by  hydatidiform  mole  formation,  it  would  appear 
that  the  latter  abnormality  must  occur  more  frequently  than  is  indicated  by  the 
statements  in  the  literature. 

Abnormalities  in  the  amount  of  liquor  amnii  are  frequently  observed,  and  most 
cases  of  advanced  tubal  pregnancy  are  characterized  by  a  diminution  in  its  quantity 
which  no  doubt  plays  an  important  part  in  the  production  of  fetal  deformities.  On 
the  other  hand,  hydramnios  may  occasionally  be  observed.  Parry  mentioned  the 
cases  described  by  Vassal,  and  Depaul,  and  since  then  similar  observations  have 
been  made  by  Teuffel,  Webster,  Lindfors,  and  others.  In  the  last  two  cases  the 
amnion  contained,  respectively,  25  and  12  liters  of  fluid. 

Various  unimportant  abnormalities  of  the  placenta  have  also  been  described  in 
advanced  cases,  although  no  one  has  as  yet  reported  syphilitic  lesions  in  the  fetus 
or  placenta,  but  in  view  of  their  marked  frequency  in  uterine  pregnancy,  it  is  more 
than  likely  that  they  will  soon  be  described. 

Cases  reported  by  Spiegelberg  and  Hoist  occupy  almost  unique  positions  in  the 
history  of  extrauterine  pregnancy,  as  the  patients  had  eclampsia  during  false  labor. 


SYMPTOMS. 

Unfortunately  the  symptoms  of  uninterrupted  extrauterine  pregnancy  are  not 
characteristic,  and  therefore  the  patient  and  her  physician  are  usually  entirely  un- 
aware of  its  existence  until  rupture  or  tubal  abortion  occurs.  In  many  instances  the 
patient  considers  herself  pregnant,  and  presents  the  usual  subjective  symptoms  of 
that  condition.  She  may  complain  of  slight  pain  in  one  or  other  ovarian  region, 
to  which  she  pays  but  little  attention.  Less  frequently  she  has  no  idea  that  she  is 
pregnant,  and  rupture  may  occur  and  end  fatally  before  a  menstrual  period  has  been 
missed.  Thus,  I  know  of  a  multiparous  woman,  with  a  perfectly  normal  menstrual 
history,  who  died  from  hemorrhage  following  rupture  fifteen  days  after  her  last 
period;  and  similar  cases  have  been  reported  by  Orthmann,  Duncan,  Spencer, 
Gottschalk,  and  others. 

Suppression  of  the  menses  does  not  occur  so  regularly  in  extrauterine  as  in  nor- 
mal pregnancy,  and  the  experience  of  recent  writers  tends  to  show  that  it  is  of  com- 
paratively little  diagnostic  value;  since  menstruation  persisted  in  43  per  cent,  of 
131  cases  observed  by  Martin  and  Orthmann,  Bouilly  and  Wormser.  Such  state- 
ments, however,  do  not  necessarily  indicate  that  the  patient  is  menstruating  nor- 

VOL.  II — 11 


162  EXTRAUTERINE  PREGNANCY. 

mally;  as  the  hemorrhage  is  frequently  due  to  an  endometritis.  Moreover,  if 
the  fetus  dies  at  an  early  period  and  rupture  or  abortion  does  not  occur,  there 
is  usually  more  or  less  uterine  hemorrhage,  which  may  be  mistaken  for  the  men- 
strual flow  or  an  early  abortion,  the  possibility  of  the  latter  being  still  further  con- 
firmed by  the  discharge  of  the  uterine  decidua,  which  is  usually  cast  off  in  shreds 
or  small  pieces,  and  only  rarely  as  a  characteristic  triangular  cast. 

This  being  the  case,  it  frequently  happens  that  the  first  sign  of  the  existence  of 
the  abnormal  pregnancy  is  afforded  by  sudden  lancinating  pain  in  one  or  other 
ovarian  region,  which  is  soon  followed  by  marked  faintness  on  the  part  of  the  patient, 
who  becomes  extremely  pallid,  rapidly  passes  into  a  condition  of  collapse,  and  may 
present  a  subnormal  temperature.  Such  a  condition  indicates  rupture  of  the  tube 
with  free  hemorrhage  into  the  peritoneal  cavity.  Under  such  circumstances  the 
collapse  and  other  symptoms  of  internal  hemorrhage  rapidly  become  more  pro- 
nounced, and  the  patient  may  die  in  a  few  hours  unless  saved  by  operative  aid. 
Occasionally,  however,  the  primary  hemorrhage  is  not  sufficiently  severe  to  cause 
death,  and  the  patient  may  gradually  recover  from  the  first  attack,  only  to  have  it 
recur  at  a  later  period. 

On  the  other  hand,  if  the  symptoms  of  collapse  are  not  so  pronounced  the  prob- 
abilities are  that  one  has  to  deal  with  a  tubal  abortion,  which  is  accompanied  by  a 
trickling  of  blood  into  the  abdominal  cavity  through  the  Fallopian  tube.  In  such 
cases  the  general  condition  of  the  patient  is  not  as  a  rule  alarming,  and  she  gradually 
recovers  from  the  acute  attack,  while  vaginal  examination  a  few  days  later  shows 
that  the  pelvic  cavity  is  filled  out  to  a  greater  or  less  extent  by  a  fluctuating  tumor — 
pelvic  hematocele. 

In  all  the  earlier  text-books  upon  gynecology,  pelvic  hematocele  was  considered 
as  a  distinct  disease,  and  its  connection  with  extrauterine  pregnancy  was  not  fully 
established  until  Veit,  in  1877  and  1884,  clearly  demonstrated  that  most  cases  had 
been  preceded  by  symptoms  referable  to  tubal  pregnancy.  According  to  Pilliet, 
Aran  in  1855  was  the  first  to  direct  attention  to  this  fact,  but  his  work  did  not  attract 
the  attention  it  deserved,  and  practically  passed  unnoticed.  Tait  held  that  this 
was  a  universal  rule,  and  that  the  mere  existence  of  ajiematocele  afforded  positive 
evidence  of  extrauterine  pregnancy. 

It  appears,  however,  that  this  is  too  extreme  a  view,  and  most  modern  writers, 
while  admitting  its  general  correctness,  believe  that  hematocele  formation  may 
occasionally  result  in  other  ways.  Thus,  Thorn  demonstrated  such  a  connection  in 
57  per  cent,  of  his  cases,  and  Cullingworth  noted  it  in  twenty-three  out  of  his  twenty- 
four  cases  of  hematocele. 

As  has  already  been  indicated,  hematocele  formation  usually  follows  tubal 
abortion;  but  it  may  likewise  occur  after  rupture,  provided  the  hemorrhage  is  not 
too  profuse.  It  is  customary  to  distinguish  between  diffuse  and  solitary  hematocele, 
according  as  the  collection  of  blood  occupies  a  considerable  part  of  the  pelvic  cavity, 
or  is  restricted  to  the  neighborhood  of  the  fimbriated  extremity  of  the  tube. 

The  diffuse  variety  usually  occurs  when  adhesions  are  already  present  between 


SYMPTOMS.  163 

pelvic  organs.  These  facilitate  the  coagulation  of  the  blood  and  aid  in  the  forma- 
tion of  an  organized  membrane  over  it,  by  which  it  is  shut  off  from  the  abdominal 
cavity.  Owing  to  its  formation  about  existing  adhesions,  the  removal  of  such  a 
hematocele  is  not  always  easy,  as  it  cannot  be  shelled  out  of  the  pelvic  cavity  until 
the  original  adhesions  are  broken  through. 

According  to  Sanger,  on  the  other  hand,  the  existence  of  adhesions  is  not  essen- 
tial to  the  formation  of  the  solitary  hematocele.  He  held  that  such  a  structure 
might  be  formed  when  the  blood  trickled  slowly  enough  from  the  fimbriated  end  of 
the  tube  to  permit  the  coagulation  of  its  outer  portion,  thereby  giving  rise  to  a  cap- 
sule which  became  organized  and  gradually  enlarged  as  the  blood  was  poured  out 
into  its  interior.  As  the  solitary  hematocele  enlarges  it  comes  in  contact  with  and 
often  adheres  to  the  surrounding  structures,  but  it  can  usually  be  removed  at  opera- 
tion without  great  difficulty,  being  peeled  out  from  the  pelvic  cavity  just  as  an  ordi- 
nary tubal  or  ovarian  tumor. 

Hematocele  formation,  whether  diffuse  or  solitary,  is  a  very  favorable  termination 
of  tubal  pregnancy;  for,  if  let  alone,  it  is  gradually  absorbed  and  complete  recovery 
of  the  patient  results.  Thorn,  for  example,  has  reported  157  cases  with  a  mortality 
of  0.6  per  cent,  and  Fehling  91  cases  without  a  single  death.  It  should  not  be  under- 
stood, however,  that  it  is  universally  favorable,  for  occasionally  the  hemorrhage  may 
persist  and  the  hematocele  become  larger  and  larger,  until  at  last  its  capsule  rup- 
tures and  pours  its  contents  out  into  the  peritoneal  cavity;  while  in  not  a  few  cases 
intestinal  bacteria  may  make  their  way  into  it  and  give  rise  to  suppuration. 

If  the  patient  does  not  succumb  to  the  collapse  following  rupture,  and  if  the 
placenta  has  not  been  separated  to  too  great  an  extent,  a  secondary  abdominal  preg- 
nancy may  result  and  the  fetus  may  continue  its  existence.  Under  such  circum- 
stances the  usual  symptoms  of  pregnancy  persist,  except  that  the  patient  suffers 
more  pain  and  feels  the  fetal  movements  more  acutely  than  in  uterine  pregnancy. 
No  doubt  part  of  the  pain  is  due  to  the  distention  and  possibly  to  contractions  of 
the  fetal  sac,  but  the  greater  part  of  it  must  be  attributed  to  the  stretching  of 
adhesions  which  have  formed  between  it  and  the  various  abdominal  organs. 

In  the  exceptional  cases,  in  which  the  primary  rupture  occurred  into  the  broad 
ligament,  secondary  rupture  may  occur  at  a  later  period,  and  lead  to  death  from 
hemorrhage  or  to  a  secondary  abdominal  pregnancy.  In  the  latter  case  the  fetus 
will  lie  in  the  peritoneal  cavity,  while  the  placenta  remains  within  the  folds  of  the 
broad  ligament. 

If  the  secondary  abdominal  pregnancy  or  the  very  rare  cases  of  unruptured  tubal 
or  ovarian  pregnancy  continue,  false  labor  sets  in  at  term,  and  is  accompanied  by 
distinct  contractions,  similar  to  those  in  the  early  stages  of  normal  labor,  but  which, 
of  course,  can  have  no  effect  upon  the  birth  of  the  extrauterine  child.  The  pains 
are  due  to  uterine  contractions,  as  in  the  majority  of  cases  the  fetal  sac,  even  if 
unruptured,  contains  so  few  muscular  fibers  that  its  contraction  is  practically 
impossible.  Exceptionally,  however,  as  in  a  case  reported  by  Pinard,  it  may  be 
richer  than  usual  in  muscular  tissue  and  give  rise  to  definite  contractions. 


164  EXTRAUTERINE  PREGNANCY. 

False  labor  may  last  for  a  few  hours  or  a  number  of  days,  and  is  soon  followed 
by  the  death  of  the  child,  although  in  a  small  number  of  cases  fetal  movements 
have  been  felt  for  a  considerable  time  afterward.  After  the  death  of  the  fetus  the 
placental  circulation  gradually  becomes  aboHshed,  the  intervillous  spaces  become 
filled  with  fibrin,  and  the  chorionic  villi  undergo  degenerative  changes.  At  the  same 
time  the  amniotic  fluid  is  absorbed  and  the  fetal  sac  becomes  retracted  over  the 
more  or  less  mummified  fetus,  so  that  it  occupies  a  much  smaller  space  than  formerly. 
The  abdomen,  in  consequence,  becomes  smaller  and  its  change  in  size  is  soon  noticed 
by  the  patient. 

After  its  initial  shrinking  the  tumor  may  remain  stationary  for  a  number  of 
years,  the  child  within  it  becoming  mummified  or  converted  into  a  lithopedion; 
while  in  other  cases  inflammatory  symptoms  make  their  appearance,  and  an  ab- 
scess is  formed,  which  may  rupture  externally  and  be  followed  by  a  gradual  dis- 
charge of  the  fetus,  or  lead  to  the  death  of  the  patient  from  exhaustion  or  peritonitis. 

Combined  and  Multiple  Pregnancy. — Parry  stated  in  his  monograph  that  22 
out  of  the  500  cases  of  tubal  pregnancy  which  he  collected  were  also  associated  with 
intrauterine  pregnancy,  and  designated  the  condition  as  combined  pregnancy. 
Since  then  a  number  of  authors  have  written  upon  the  subject,  and  many  additional 
cases  have  been  reported.  B.  B.  Browne  read  a  paper  upon  the  subject  in  1882, 
before  the  American  Gynecological  Society,  and,  while  apparently  ignorant  of  the 
work  of  Parry,  collected  nearly  all  the  cases  to  which  he  referred  and  added  four 
additional  ones. 

Since  1896  the  condition  has  been  frequently  observed  and  a  number  of  mono- 
graphs have  been  written  upon  the  subject  by  Pantellani,  Gutzwiller,  ]Moseley, 
Strauss,  Zincke,  Christer-Nilsson,  Bichat,  Simpson,  and  Weibel.  Some  idea  of  the 
increase  may  be  obtained  from  the  fact  that  Strauss  in  1898  was  able  to  collect  from 
the  literature  but  32  cases,  while  Weibel  in  1905  had  increased  the  number  to  119. 

It  should  also  be  noted  that  in  the  more  recent  collections  of  cases  only  those 
have  been  included  in  which  both  the  intrauterine  and  extrauterine  pregnancies 
were  of  the  same  age,  and  no  account  is  taken  of  the  cases  in  which  uterine  concep- 
tion occurred  while  the  patient  was  carrying  within  her  the  remains  of  an  old  ex- 
trauterine pregnancy. 

In  rarer  instances  twin  tubal  pregnancy  has  been  observed,  the  two  embryos 
being  sometimes  in  the  same  tube,  while  in  other  cases  one  was  found  in  each  tube. 
Several  such  cases  are  mentioned  in  the  monographs  of  Hennig,  Parry,  and  Web- 
ster, while  the  more  recent  cases  were  collected  in  1904  by  Jayle  and  Naudrot. 

Sanger  and  Krusen  have  reported  cases  of  triplet  tubal  pregnancy,  all  of  the 
embryos  being  of  the  same  age. 

Repeated  Tubal  Pregnancy. — Parry  collected  eight  cases  of  this  character 
from  the  literature,  and  stated  that  Primrose  had  made  the  first  observation  in  1594. 
These  early  cases,  however,  are  of  very  questionable  value,  as  the  case  of  Haydon 
in  1863  was  the  only  one  to  be  confirmed  by  autopsy. 

With  the  modern  development  of  abdominal  surgery,  however,  the  abnormal- 


DIAGNOSIS.  165 

ity  has  been  observed  quite  frequently.  Abel  in  1893  collected  the  first  series  of 
cases,  while  the  articles  of  ^Yeil  in  1901  and  Heikel  in  1903  have  shown  that  it  is  not 
an  unusual  occurrence.  In  several  instances  only  a  few  months  elapsed  between 
the  two  pregnancies,  while  in  others  they  were  separated  by  a  period  of  vears.  I 
operated  twice  upon  the  same  patient  at  an  interval  of  eighteen  months,  and  Charles 
P.  Noble  after  an  interval  of  only  six  months. 

One  of  the  most  interesting  cases  of  this  character  was  reported  by  H.  C.  Coe,  who 
kindly  sent  me  the  specimen  for  examination.  In  this  instance  an  interval  of  eleven 
years  had  elapsed  between  the  two  pregnancies,  and  at  the  operation  a  freshlv  rup- 
tured four  months'  pregnancy  was  found  at  the  lateral  end  and  a  lithopedion  in  the 
isthmic  portion  of  the  same  tube.  The  case  was  also  of  interest,  as  it  conclusively 
demonstrated  the  occurrence  of  external  migration  of  the  ovum,  a  fresh  corpus  luteum 
having  been  found  in  the  ovary  opposite  the  pregnant  tube.  As  the  lithopedion 
completely  occluded  the  median  portion  of  the  pregnant  tube,  it  is  apparent  that 
the  spermatozoa  must  have  traversed  the  opposite  tube  and  fertilized  the  ovum 
soon  after  it  left  the  ovary,  after  which  it  was  carried  to  the  other  tube,  which  it 
descended  until  arrested  by  the  lithopedion. 

The  Effect  upon  Subsequent  Child-bearing. — In  a  considerable  number  of 
cases  the  presence  of  an  old  extrauterine  pregnancy  exerts  no  influence  upon  the 
course  of  subsequent  labors.  This  was  first  demonstrated  by  the  patient  from  whom 
the  Leinzell  lithopedion  was  obtained,  as  she  had  two  spontaneous  labors  while 
carrying  it.  Similar  cases  are  not  rare,  and  it  is  interesting  to  note  that  two  of  the 
earliest  cases  of  extrauterine  pregnancy  observed  in  this  country  were  of  the  same 
character.  Thus,  the  patient  reported  by  Osgood  in  1745  had  six  subsequent  labors; 
while  in  John  Bard's  case  in  1759  a  single  spontaneous  labor  followed. 

Occasionally,  however,  the  remains  of  an  old  extrauterine  pregnancy  give  rise 
to  serious  dystocia,  and  have  necessitated  the  performance  of  major  obstetric 
operations  in  subsequent  labors.  Thus,  the  pelvic  canal  was  so  obstructed  in  the 
cases  of  Hugenberger,  Schauta,  and  Sanger  that  Cesarean  section  was  required, 
which  would  also  have  been  necessary  in  Ott's  case  had  a  miscarriage  not  occurred 
at  the  sixth  month.  Likewise  premature  labor  was  induced  by  Hennigsen,  Dibot, 
and  Brossi,  while  Stein  the  younger  and  Cheston  performed  craniotomy  under  the 
same  circumstances. 

That  such  difficulties,  however,  are  not  usual,  is  shown  by  the  careful  study  of 
Funck-Brentano,  who  has  collected  126  cases  of  spontaneous  labor  following  ex- 
trauterine pregnancy — 92  occurring  while  the  patients  were  still  carrying  the  re- 
mains of  the  old  condition,  and  34  some  time  after  its  removal  by  operation. 


DIAGNOSIS. 
Unfortunately  early  unruptured  extrauterine  pregnancy  is  rarely  diagnosticated, 
as  the  symptoms  to  which  it  gives  rise  are  usually  too  slight  to  cause  the  patient  to 
consult  a  physician,  and  the  majority  of  English  and  American  writers  follow  the 


166  EXTKAUTERINE  PREGNANCY. 

example  of  Tait  and  believe  that  such  a  diagnosis  cannot  be  made.  As  far  as  I 
can  learn,  Yeit  in  1883  was  the  first  to  confirm  by  operation  a  positive  diagnosis  of 
this  character,  while  Janvrin  in  1888  was  apparently  the  first  American  to  do  likewise. 

Such  a  diagnosis  is  based  upon  finding  a  unilateral  tubal  tumor  in  a  patient 
presenting  the  usual  subjective  and  objective  symptoms  of  early  pregnancy,  especi- 
ally if  she  has  been  sterile  for  a  number  of  years,  or  if  a  long  interval  has  elapsed 
since  her  last  pregnancy.  The  uterus  is  somewhat  enlarged  and  softened  and  the 
tubal  tumor  is  soft  and  doughy,  and  roughly  corresponds  in  size  to  the  supposed 
duration  of  the  pregnancy;  but  the  experience  of  most  operators,  after  making  such 
a  diagnosis,  is  to  find  at  operation  that  the  tumor  is  of  some  other  nature.  Occa- 
sionally a  sacculated  condition  of  the  pregnant  uterus  may  apparently  offer  the 
physical  signs  of  an  unruptured  extrauterine  pregnancy,  and  I  operated  upon  a  case 
of  this  kind  only  to  find  the  ovum  inside  of  the  uterus. 

As  Taylor  has  pointed  out,  the  unruptured  pregnant  tube  frequently  pro- 
lapses into  Douglas'  cul-de-sac,  and  may  be  mistaken  for  a  retroflexed  pregnant 
uterus,  and  not  a  few  cases  have  been  reported  in  which  rupture  followed  an  attempt 
to  replace  it. 

Even  after  the  death  of  the  fetus  a  positive  diagnosis  is  not  readily  made  unless 
rupture  of  the  fetal  sac  has  occurred,  and  the  majority  of  such  cases  are  mistaken 
for  uterine  abortion  or  tubal  tumors  of  inflammatory  origin.  The  possibility  of 
the  first  mistake  was  first  emphasized  by  Wyder  in  1886,  who  stated  that  one  should 
never  attempt  to  empty  the  uterus  in  cases  of  suspected  incomplete  abortion,  with- 
out having  previously  carefully  palpated  the  tubes  and  ovaries;  and  if  a  tumor  is 
found  on  one  or  other  side  of  the  uterus,  the  possibility  of  the  existence  of  a  tubal 
pregnancy  is  very  great.  The  possibility  of  error  is  due  to  the  fact  that  in  tubal 
pregnancy  fetal  death  is  usually  associated  with  some  uterine  hemorrhage  and  the 
discharge  of  decidual  tissue.  Occasionally,  the  latter  is  discharged  intact  as  a  tri- 
angular cast  of  the  uterine  ca\aty,  but  more  frequently  it  comes  away  in  shreds, 
which  are  mistaken  by  the  patient  for  portions  of  the  ovum.  Moreover,  the  fact  that 
the  patient  usually  destroys  whatever  is  discharged  from  the  uterus,  increases  the 
possibility  of  error,  as  the  physician  is  obliged  to  rely  upon  her  statements  as  to  its 
appearance. 

It  is  generally  taught  that  the  discharge  of  an  intact  decidual  cast  is  a  charac- 
teristic sign  of  extrauterine  pregnancy,  and  no  doubt  this  holds  good  in  the  majority  of 
cases;  but  occasionally  a  similar  structure  may  be  discharged  without  the  existence 
of  pregnancy  of  any  kind.  This  was  demonstrated  by  the  experience  of  Griffiths 
and  Dakin,  who  diagnosticated  extrauterine  pregnancy  from  the  discharge  of  such 
a  cast,  and  at  operation  the  former  found  the  pelvic  organs  perfectly  intact  and  the 
latter  a  small  ovarian  cyst.  Eden  had  a  similar  experience,  except  that  he  did  not 
operate,  as  a  very  careful  examination  of  the  patient  by  Herman  absolutely  pre- 
cluded the  existence  of  such  a  condition. 

Ott,  Ayres,  and  others  believe  that  the  discharge  of  a  decidual  membrane  or  the 
presence  of  decidual  tissue  in  the  empty  uterus,  when  a  tumor  mass  can  be  detected 


DIAGNOSIS.  167 

on  one  side  of  it,  is  a  positive  diagnostic  sign  of  extrauterine  pregnancy,  and,  in 
doubtful  cases,  recommend  curetting  the  uterus  for  diagnostic  purposes.  ]\Iy  own 
experience  has  taught  me  that,  while  the  presence  of  decidua  under  such  circum- 
stances usually  affords  strong  presumptive  evidence,  its  absence  is  not  equally  con- 
vincing from  a  negative  point  of  view.  For  occasionally  the  decidua  may  have  been 
cast  off  at  an  early  period  and  become  replaced  by  normal  endometrium,  so  that  the 
examination  of  the  material  removed  will  be  negative.  Pilliet  and  Cazeaux  report 
a  similar  experience. 

Taking  all  these  factors  into  consideration,  a  probable  diagnosis  can  usually  be 
made  after  fetal  death,  but  before  the  occurrence  of  rupture  or  abortion,  and  is  based 
upon  the  history  of  the  patient  and  the  findings  upon  vaginal  examination.  Its 
possibility  should  always  be  considered  when  a  patient,  after  amenorrhea  lasting  a 
few  weeks  or  months,  complains  of  uterine  hemorrhage  and  the  discharge  of  shreds 
of  tissue,  in  which  no  trace  of  a  fetus  can  be  found,  especially  if  she  presents  a  his- 
tory of  sterility  or  previous  pelvic  inflammatory  trouble.  Furthermore,  the  diag- 
nosis is  rendered  very  probable  when  vaginal  examination  shows  a  somewhat 
enlarged  uterus  and  a  tubal  tumor,  v/hich  corresponds  in  size  to  the  supposed  dura- 
tion of  the  pregnancy.  In  not  a  few  cases,  on  the  other  hand,  operation  will  show 
that  the  supposed  pregnancy  is  nothing  but  a  pelvic  inflammatory  mass  or  a  small 
ovarian  tumor. 

If  a  patient  with  the  above  history,  or  even  one  who  does  not  suspect  the  existence 
of  pregnancy,  suddenly  becomes  faint,  pallid,  or  unconscious,  and  then  passes  into 
a  condition  of  collapse,  the  diagnosis  of  ruptured  tubal  pregnancy  or  of  tubal  abor- 
tion with  profuse  intraperitoneal  hemorrhage  becomes  practically  certain,  and  at 
operation  a  large  quantity  of  blood  will  usually  be  found  in  the  peritoneal  cavity. 
Unfortunately  vaginal  examination  in  these  cases  reveals  but  little,  as  the  patient 
is  usually  so  extremely  sensitive  that  an  accurate  examination  is  impossible. 

If  the  symptoms  of  collapse  are  very  marked  and  the  patient  is  pallid  and  pre- 
sents a  subnormal  temperature,  the  diagnosis  of  rupture  is  positive.  On  the  con- 
trary, in  tubal  abortion  the  collapse  may  be  quite  marked  and  out  of  all  proportion 
to  the  amount  of  blood  lost,  but  is  not  associated  with  pallor  or  subnormal  tempera- 
ture, so  that,  as  Bouilly  has  pointed  out,  the  presence  or  absence  of  the  last  two 
symptoms  may  be  of  considerable  diagnostic  value.  Moreover,  if  the  patient  rapidly 
recovers  from  the  collapse,  the  probabilities  are  in  favor  of  tubal  abortion,  while  the 
subsequent  formation  of  a  hematocele  practically  settles  the  question. 

As  has  already  been  pointed  out,  rupture  may  occur  at  a  very  early  period,  and 
even  before  the  patient  believes  herself  pregnant.  Therefore,  in  a  woman  during  the 
childbearing  period,  one  should  regard  sudden  collapse  associated  with  the  symp- 
toms of  intra-abdominal  hemorrhage  as  prima  facie  evidence  of  ruptured  tubal 
pregnancy,  even  though  a  menstrual  period  has  not  been  missed.  By  so  doing, 
and  operating  promptly  in  suitable  cases,  a  number  of  lives  may  be  saved  which 
otherwise  would  inevitably  be  lost. 

The  majority  of  cases,  however,  come  into  the  hands  of  the  operator  after  the 


168  EXTRAUTERINE  PREGNANCY. 

patient  has  recovered  from  the  primary  shock,  and  under  such  circumstances 
vaginal  examination  will  show  a  mass  on  one  side  of  the  uterus  which  may  or  may 
not  be  the  result  of  extrauterine  pregnancy.  Such  cases  are  usually  mistaken  for 
pelvic  inflammatory  troubles  or  vice  versa.  When  a  mass  containing  fluid  can  be 
felt  posterior  or  lateral  to  the  uterus,  exploratory  vaginal  puncture  followed  by  the 
escape  of  bloody  fluid  establishes  the  existence  of  a  hematocele,  though  I  do  not 
recommend  such  a  procedure  for  diagnostic  purposes. 

If  the  child  has  survived  the  rupture,  a  correct  diagnosis  is  rarely  made  until 
full  term  is  reached,  unless  one's  attention  is  particularly  directed  to  its  possibility 
by  the  previous  history  of  the  case.  Under  such  circumstances  the  true  condition 
of  affairs  is  readily  recognized,  as  the  uterus  will  be  found  enlarged  to  about  the 
size  of  a  three  months'  pregnancy,  while  the  child  lies  in  a  sac  outside  of  it  or  even 
free  in  the  abdominal  cavity  and  can  be  palpated  much  more  readily  than  usual. 
When  the  diagnosis  is  doubtful  the  introduction  of  a  sound  into  the  uterus  is  per- 
missible; on  the  other  hand,  if  the  previous  history  is  not  known,  and  the  patient  is 
not  carefully  examined,  she  will  usually  be  considered  as  normally  pregnant  until 
the  occurrence  of  false  labor  teaches  otherw^ise. 

When  the  pregnancy  continues  after  rupture  into  the  broad  ligament,  the  diag- 
nosis may  be  confirmed  by  finding  a  tumor  intimately  connected  with  the  uterus, 
and  depressing  the  vaginal  vault  laterally  or  even  posteriorly  to  it,  instead  of  lying 
higher  up  in  the  abdominal  cavity. 

After  extrauterine  pregnancy  has  reached  full  term,  the  diagnosis  is  usually 
easy,  and  is  based  upon  a  history  of  false  labor,  followed  by  a  gradual  decrease  in 
the  size  of  the  abdomen.  Physical  examination  in  such  cases  will  show  the  uterus 
practically  normal  in  size  and  pressed  against  the  symphysis  or  down  into  the  pelvis 
by  a  large  tumor  more  or  less  closely  connected  with  it,  in  which  the  outlines  of 
the  child  can  occasionally  be  distinguished.  In  exceptional  instances,  where  the 
child  is  surrounded  by  a  greater  quantity  of  amniotic  fluid  than  usual,  the  fetal  sac 
may  be  mistaken  for  an  ovarian  tumor,  as  in  the  case  reported  by  Teuffel. 

To  recapitulate,  a  positive  diagnosis  of  unruptured  tubal  pregnancy  can  occa- 
sionally be  made;  but  the  vast  majority  of  cases  escape  detection  until  rupture  or 
abortion  has  occurred,  when  the  diagnosis  is  readily  established.  In  advanced  cases 
careful  examination  will  usually  lead  to  correct  diagnosis,  while  after  false  labor 
the  history  is  so  characteristic  that  mistakes  should  rarely  be  made. 

The  diagnosis  of  combined  intrauterine  and  extrauterine  pregnancy  is  rarely 
made  until  the  abortion  of  the  former  or  the  rupture  of  the  latter  leads  to  a  minute 
examination  of  the  patient,  and  even  then  one  of  the  pregnancies  may  occasionally 
be  overlooked  until  operation  or  autopsy.  The  condition  has  never  been  diagnosti- 
cated in  the  later  months,  though  in  several  instances  the  existence  of  twins  has  been 
detected,  but  the  possibility  of  combined  pregnancy  was  not  considered  until  after 
the  delivery  of  the  uterine  child,  when  an  attempt  to  find  a  cause  for  the  delayed 
birth  of  the  other  revealed  the  fact  that  it  lay  outside  of  the  uterine  cavity. 


TREATMENT.  169 


TREATMENT. 

When  unruptured  extrauterine  pregnancy  is  diagnosticated,  its  prompt  removal 
by  laparotomy  is  urgently  indicated,  as  rupture  may  occur  at  any  time  and  cause 
the  death  of  the  patient  before  art  can  come  to  her  aid. 

The  importance  of  immediate  operation  cannot  be  too  strongly  emphasized, 
and  all  methods  which  aim  to  destroy  the  fetus  and  thus  terminate  the  pregnancy 
without  operation  are,  to  my  mind  at  least,  absolutely  unjustifiable.  This  applies 
not  only  to  the  use  of  electricity,  but  also  to  the  injection  of  poisonous  substances 
into  the  gestation  sac.  Even  admitting  the  possibility  of  destroying  the  fetus  by 
such  means,  the  danger  to  the  mother  is  not  at  an  end,  as  we  know  that  rupture 
may  take  place  after  its  death;  and  even  should  this  fail  to  occur,  the  retention  of 
the  product  of  conception  in  the  tube  renders  it  a  useless  organ  and  may  expose 
the  patient  to  considerable  danger.  Unfortunately,  however,  it  is  only  rarely  that 
one  has  to  consider  the  treatment  of  such  cases,  as  the  diagnosis  is  usually  not  made 
until  rupture  or  tubal  abortion  has  occurred. 

Tait,  in  1883,  was  the  first  to  perform  laparotomy  for  ruptured  tubal  pregnancy, 
and  since  he  demonstrated  the  ease  with  which  the  operation  could  be  performed 
and  the  surprisingly  good  results  which  followed  it,  all  gynecologists  have  followed 
his  example,  and  most  of  us  can  recall  many  cases  which  have  been  saved  in  this 
way,  which  otherwise  would  have  been  hopelessly  lost. 

The  performance  of  laparotomy  for  the  purpose  of  checking  hemorrhage  from  a 
ruptured  tubal  pregnancy  was  first  suggested  by  W.  W.  Harbert,  in  1849.  Stephen 
Rogers,  in  a  monograph  in  1867,  stated,  "  the  peritoneal  cavity  must  be  opened,  the 
bleeding  vessels  must  be  ligated";  and  further  on:  "^Yhat  would  we  say  of  a  sur- 
geon who  would  sit  quietly  by  and  see  the  life-blood  flow  from  a  divided  vein  or 
artery,  and  make  no  effort  to  arrest  it  ?  He  who  recognizes  the  presence  of  blood 
in  the  peritoneal  cavity,  with  a  coincident  history,  such  as  has  been  detailed  above, 
has  no  better  excuse  for  inaction."  The  propriety  of  operation  was  also  most 
eloquently  urged  by  Parry  in  1876,  but  Tait  was  the  first  who  had  the  courage  to 
adopt  their  suggestions. 

The  beneficent  effects  of  the  operation  were  soon  recognized,  and  were  clearly 
demonstrated  by  the  statistics  of  Schauta,  who,  after  a  careful  study  of  the  litera- 
ture, compared  the  results  following  operation  in  123  cases  with  those  observed  in 
121  cases  treated  palliatively,  and  reported  a  mortahty  of  5.7  and  86.89  per  cent, 
respectively. 

At  present  every  one  agrees  as  to  the  propriety  of  operation  in  suitable  cases, 
and  merely  has  to  determine  when  it  is  indicated  and  how  it  is  best  performed. 

In  every  case  in  which  the  collapse  is  marked  and  the  patient  presents  a  pallid 
appearance  and  subnormal  temperature,  immediate  laparotomy  is  indicated,  unless 
her  condition  is  so  desperate  that  death  appears  imminent,  and  even  under  such 
circumstances  recovery  sometimes  follows  prompt  operation. 

The  abdomen  should  be  opened  rapidly,  under  cocain  anesthesia  if  necessary, 


170  EXTRAUTERINE  PREGNANCY. 

the  hand  passed  down  alongside  the  uterus  and  the  tubal  mass  seized  and  clamped 
on  both  sides  by  long  forceps,  after  which  the  mass  may  be  removed  and  the  clamps 
replaced  by  ligatures  at  comparative  leisure.  In  many  cases  the  abdomen  is  filled 
with  blood,  which  spurts  from  the  wound  as  soon  as  the  peritoneum  is  incised,  and 
completely  obscures  the  field  of  operation.  Under  such  circumstances  the  clamps 
should  be  applied  by  the  sense  of  touch,  without  attempting  to  clean  out  the  pelvic 
cavity,  after  which  the  blood-clots  may  be  removed  and  the  field  of  operation  cleaned 
up  so  as  to  enable  one  to  complete  the  operation  under  the  guidance  of  the  eye.  After 
removing  the  fetal  sac  and  ligating  the  vessels,  it  is  not  necessary  to  remove  all  the 
blood  from  the  peritoneal  cavity  unless  the  patient's  condition  is  fairly  satisfactory, 
as  one  may  lose  more  by  attempting  to  do  so  than  by  allowing  a  small  amount  to 
remain  behind. 

Not  infrequently  the  tube  and  ovary  on  the  other  side  may  be  the  seat  of  chronic 
inflammatory  lesions,  and  their  removal  should  depend  upon  the  condition  of  the 
patient,  it  being  far  better  to  allow  them  to  remain  than  to  run  any  risk  with  a  very 
ill  woman. 

Sippel's  suggestion  of  placing  the  patient  in  the  Trendelenburg  position  and  in- 
fusing with  salt  solution,  either  subcutaneously  or  intravenously,  while  the  neces- 
sary preparations  for  the  operation  are  being  made,  may  be  followed  with  advan- 
tage if  the  conditions  are  desperate ;  while  in  other  cases  an  intravenous  injection 
of  salt  solution  may  be  commenced  almost  simultaneously  with  the  administration 
of  the  anesthetic. 

When  laparotomy  has  been  undertaken  in  cases  of  tubal  abortion,  Prochownik, 
Martin,  and  others  have  advocated  attempting  to  save  the  pregnant  tube  if  possible, 
by  opening  it,  removing  the  products  of  conception,  and  then  repairing  it  by  suture. 
Such  a  procedure  may  occasionally  be  admissible,  but  it  has  not  yet  been  demon- 
strated that  a  tube  so  treated  regains  its  normal  function. 

Of  late  years  Martin,  Diihrssen,  and  many  others  have  advocated  attacking 
extrauterine  pregnancy  from  the  vagina.  I,  however,  do  not  believe  that  it  is  the 
most  suitable  method  of  operating  in  freshly  ruptured  cases,  although  it  may  give 
equally  good  results  under  other  circumstances,  when  its  employment  should  be 
governed  by  the  predilections  of  the  operator.  The  advantages  which  are  claimed 
for  it  are  avoidance  of  an  abdominal  incision  and  the  subsequent  danger  of  hernia, 
the  lessening  of  shock  to  the  patient,  and  the  increased  rapidity  of  convalescence. 
But  against  these  must  be  placed  the  added  difficulty  of  the  operation,  the  limited 
view  of  the  field  of  operation,  and  the  possibility  of  not  being  able  to  complete  it 
by  the  vaginal  route,  and  of  being  obliged  to  resort  to  laparotomy  to  check  hemor- 
rhage. Those  who  are  particularly  interested  in  the  subject  I  would  refer  to  the 
articles  of  Henrotin  and  Segond,  who  have  considered  the  relative  merits  of  the 
two  operations. 

Turning  from  the  consideration  of  the  treatment  of  acute  hemorrhage  following 
ruptured  extrauterine  pregnancy  to  the  cases  of  hematocele  formation,  we  find  it  is 
a  subject  upon  which  most  recent  writers  express  themselves  very  conservatively; 


TREATMENT.  171 

as  it  has  been  shown  that  the  great  majority  of  such  cases  undergo  spontaneous 
cure  if  let  alone,  and  that  operation  is  necessary  only  when  suppuration  occurs  or 
when  the  hemorrhage  continues.  Thus,  Thorn  operated  upon  only  6  out  of  157 
cases  of  hematocele,  while  the  rest  were  treated  by  rest  in  bed  under  careful  supervi- 
sion, with  a  mortaUty  of  only  0.6  per  cent.;  and  Fehling  has  recently  reported  91 
similar  cases  without  a  death.  At  the  same  time  these  writers  state  that  such  treat- 
ment requires  prolonged  rest  in  bed  and  careful  watching,  the  average  stay  of  the 
patients  in  the  hospital  having  been  54.6  days,  and  they  therefore  admit  that  it 
is  frequently  not  applicable  to  women  of  the  poorer  classes,  upon  whom  laparotomy 
must  often  be  performed. 

Rapid  increase  in  the  size  of  the  hematocele  indicates  that  the  hemorrhage  is 
continuing,  and  under  such  circumstances  laparotomy  is  urgently  demanded. 
Likewise,  if  it  does  not  increase  in  size,  but  gives  rise  to  pressure  symptoms,  or  be- 
gins to  show  signs  of  infection,  prompt  operation  is  indicated.  Under  such  circum- 
stances many  operators  hold  that  vaginal  incision,  followed  by  the  removal  of  the 
blood-clot,  with  subsequent  packing,  gives  most  excellent  results.  Kelly,  Segond, 
and  others  have  demonstrated  its  advantages,  but  at  the  same  time  admit  that  con- 
ditions may  occasionally  arise  which  will  render  it  impossible  to  complete  the  opera- 
tion by  the  vagina,  and  require  immediate  laparotomy  to  check  hemorrhage.  Ac- 
cordingly, when  the  vaginal  route  is  chosen,  the  patient's  abdomen  should  also  be 
prepared  in  advance  for  laparotomy,  so  that  no  time  will  be  lost  should  it  become 
necessary  to  resort  to  it. 

From  my  own  experience  I  am  inclined  to  agree  with  Fehling,  who  believes  that 
laparotomy  is  the  operation  of  choice  in  the  cases  of  hematocele  in  which  interference 
is  required,  as  it  at  once  puts  one  in  a  position  to  do  whatever  may  be  necessary, 
without  being  compelled  to  resort  to  some  other  operation.  On  the  other  hand, 
it  would  appear  that  the  vaginal  route  is  well  adapted  for  the  evacuation  of  certain 
broad  ligament  hematomata. 

What  has  thus  far  been  said  applies  only  to  the  treatment  of  the  condition  in 
the  first  four  months  of  pregnancy.  In  the  later  months  the  methods  of  operating 
differ  considerably,  according  as  the  fetus  is  living  or  dead.  Very  exceptionally 
the  live  fetus  may  be  inclosed  in  a  tubal  or  ovarian  sac,  and  somewhat  more  fre- 
quently a  broad  ligament  pregnancy  may  have  continued  to  develop  subperitoneally, 
but  usually  one  has  to  deal  with  a  secondary  abdominal  pregnancy,  the  child  and 
its  membranes  being  in  the  peritoneal  cavity,  and  the  placenta  either  within  the 
tube  or  broadly  implanted  upon  it  and  the  floor  of  the  pelvis.  AYhatever  the 
anatomic  conditions  may  be,  advanced  extrauterine  pregnancy  with  a  living  child 
is  always  attended  with  considerable  danger  to  the  mother,  as  the  possibility  of 
sudden  hemorrhage  is  always  present;  and  I  therefore  believe  that  prompt  lapa- 
rotomy is  the  only  conservative  method  of  treatment  in  such  cases.  If  a  living 
child  is  diagnosticated  just  before  or  soon  after  the  period  of  viability,  Segond, 
Cragin,  and  others  have  urged  the  propriety  of  deferring  operation  for  a  few  weeks 
in  its  interest.     No  doubt  such  a  course  may  occasionally  be  permissible,  but 


172  EXTRAUTERINE  PREGNANCY. 

it  should  not  be  undertaken  unless  the  increased  dangers  of  waiting  are  carefully 
explained  to  the  patient  and  her  family  and  accepted  by  them. 

Generally  speaking,  immediate  operation  and  ablation  of  the  entire  fetal  sac 
is  the  ideal  procedure,  and  in  the  rare  cases  of  unruptured  tubal  or  ovarian  preg- 
nancy may  be  comparatively  simple,  as  the  fetal  sac  may  be  excised  without  much 
greater  difficulty  than  a  large,  adherent  ovarian  cyst.  Unfortunately,  such  favorable 
conditions  are  not  present  in  the  majority  of  cases,  as  the  fetal  sac  is  usually  densely 
adherent  to  surrounding  organs,  while  the  placental  attachment  may  be  spread 
over  a  broad  area,  thereby  markedly  increasing  the  difficulty  of  the  operation. 

In  broad  ligament  pregnancy,  when  the  portion  of  the  broad  hgament  immedi- 
ately adjoining  the  uterus  is  not  spread  apart  by  the  growing  ovum,  the  entire  sac 
may  be  removed  without  great  difficulty  by  following  the  suggestion  of  von  Herff  and 
ligating  the  vessels  at  the  pelvic  brim  and  at  the  uterine  cornu  before  attempting 
to  remove  the  sac.  In  many  cases,  however,  its  complete  removal  offers  considera- 
ble difficulty,  and  can  be  effected  only  by  removing  the  uterus  as  well.  The  technic 
of  Kelly  for  hysteromyomectomy,  designed  especially  for  intraHgamentous  fibroid 
tumors,  may  be  employed  to  great  advantage  in  these  cases. 

Occasionally  one  feels  that  the  removal  of  the  sac  cannot  be  attempted  without 
seriously  endangering  the  life  of  the  patient.  In  this  event  it  should  be  incised, 
taking  care  to  avoid  the  placenta  if  possible,  and  the  fetus  extracted;  after  which 
its  margins  should  be  stitched  to  the  abdominal  opening  and  its  cavity  packed  with 
gauze,  leaving  the  placenta  and  the  stump  of  the  umbilical  cord  in  situ.  Under 
such  circumstances  the  placenta  is  gradually  cast  off  spontaneously  and  comes 
away  piecemeal.  This  necessarily  entails  a  prolonged  convalescence,  but  is  a  far 
safer  procedure  than  attempting  to  remove  the  placenta.  This  rule  should  always 
be  adhered  to  except  when  partial  separation  of  the  placenta  has  already  given  rise 
to  profuse  hemorrhage,  when  its  removal  becomes  imperative,  no  matter  how  dan- 
gerous it  may  appear.  Those  who  are  particularly  interested  in  the  treatment  of 
the  placenta  in  this  class  of  cases  are  referred  to  the  thesis  of  Lescuyer,  in  which 
the  history  of  the  subject  is  exhaustively  considered.  Likewise,  when  the  placenta 
is  broadly  attached  to  the  pelvic  floor,  and  the  fetal  sac  cannot  be  stitched  to  the 
abdominal  incision,  the  immediate  removal  of  the  placenta  is  imperative,  no  matter 
how  serious  it  may  appear. 

The  results  following  primary  laparotomy  in  advanced  extrauterine  pregnancy 
with  a  living  child  have  markedly  improved  since  the  introduction  of  aseptic  methods 
of  operating.  This  is  clearly  shown  by  the  statistics  of  Harris,  who  in  1887  reported 
a  mortality  of  93  per  cent,  in  27  cases  collected  from  the  hterature,  as  compared 
with  31  per  cent,  in  145  cases  which  had  been  operated  upon  in  the  ten  years  fol- 
lowing his  first  report.  Moreover,  a  series  of  148  cases  operated  upon  since  1880, 
and  collected  by  Ayers,  shows  a  mortality  of  40.4  per  cent.  Notwithstanding  this 
marked  improvement,  it  is  nevertheless  evident  that  the  operation  is  probably  the 
most  dangerous  one  which  gynecologists  are  called  upon  to  perform ;  though  doubt- 
less improved  technic  will  gradually  result  in  a  still  further  diminution  of  its  dangers. 


LITERATURE.  173 

On  the  other  hand,  when  the  fetus  is  dead  the  conditions  are  much  more  favora- 
ble for  operation,  as  the  danger  of  hemorrhage  from  the  placental  site  rapidly  dimin- 
ishes. Therefore  the  operation  should  be  deferred,  if  possible,  for  six  or  eight  weeks 
after  the  death  of  the  fetus,  in  order  to  permit  the  obliteration  of  the  maternal 
blood  spaces  in  the  placenta,  which  usually  occurs  within  that  time,  when  it  is 
usually  possible  to  peel  off  the  placenta  without  great  hemorrhage,  and  to  close  the 
abdomen  without  drainage.  Of  course,  if  dangerous  symptoms  should  supervene 
while  one  is  waiting  for  the  obliteration  of  the  placental  circulation,  immediate 
operation  becomes  imperative.  In  any  event,  the  operation  should  not  be  delayed 
more  than  a  few  months  after  the  death  of  the  fetus,  on  account  of  the  possibility 
of  the  infection  of  the  fetal  sac  from  the  intestinal  tract,  and  subsequent  suppura- 
tion and  peritonitis.  Lusk,  in  1888,  made  an  earnest  plea  for  prompt  operation 
in  such  cases,  and  supported  his  contention  by  a  large  array  of  statistics. 

In  a  small  number  of  cases  of  this  character  operation  by  the  vaginal  route  has 
been  advocated,  but  I  believe  that  its  field  of  usefulness  is  very  limited,  as  I  agree 
with  Herman  and  Segond  that  it  should  never  be  resorted  to  unless  the  fetus  is 
firmly  impacted  in  the  pelvic  cavity,  and  depresses  the  vaginal  vault  to  such  an  ex- 
tent as  to  make  it  appear  probable  that  it  can  be  removed  without  great  difficulty. 
In  all  other  cases,  however,  laparotomy  is  the  operation  of  choice. 

It  is  interesting  to  note  that  the  first  vaginal  operation  for  extrauterine  preg- 
nancy in  this  country  was  performed  in  1816  by  Dr.  John  King,  of  Edisto  Island, 
S.  C,  when  a  full-term  child  was  removed  after  cutting  through  the  posterior  vaginal 
wall. 

LITERATURE. 

Abel:  "Zur  Anatomie  der  Eileiter-Schwangerschaft  nebst  Bemerkungen  zur  Entwickelung  der 
menschlichen  Placenta,"  Archiv  f.  Gyn.,  1891,  xxxix,  393-436. 

Abel:   "Ueber  wiederholte  Tubengraviditilt  bei  derselben  Frau,"  Archiv  f.  Gyn.,  1893,  xlv,  55-89. 

Ahlfeld:  "Ein  Fall  von  Sarcoma  uteri  deciduo-cellulare  bei  Tuben-Schwangerschaft,"  Monatsschr. 
f.  Geb.  u.  Gyn.,  1895,  i,  209-13. 

Ahlfeld:    "Lehrbuch  der  Geburtshulfe,"  1898,  II  Auf. 

Albers:    "Zur  Geschichte  des  Lithopaedion,"   Monatsschr.  f.  Geburtskunde,  1861,  xvii,  42-64. 

Andrews:  "On  the  Anatomy  of  the  Pregnant  Tube,"  Jour.  Obst.  and  Gyn.  Brit.  Emp.,  1903,  iii, 
419-41. 

Anning  and  Littlewood:  "A  Case  of  Primary  Ovarian  Pregnancy,"  Trans.  London  Obst.  Soc, 
1901,  xliii,  14-20. 

Aschoff:    "Anatomie  der  Extrauterinschwangerschaft,"   Zeigler's   Beitrage,  1889,  xxv,   Heft   2. 

Aschoff:  "Die  Beziehungen  der  tubaren  Placenta  zum  Tubenabort  und  zur  Tubenruptur,"  Archiv 
f.  Gyn.,  1900,  Ix,  523-33. 

Ashby:  "Ectopic  Pregnancy,"  Read  before  the  Obst.  Soc.  of  Baltimore,  February,  1890.  Mary- 
land Med.  Jour.,  Balto.,  1889-90,  xxii,  281,  303. 

Ayers:  "Decidua  in  the  Diagnosis  of  Extrauterine  Pregnancy,"  Amer.  Jour,  of  Obst.,  1892,  xxvi, 
289-306. 

Ayers:  "The  Management  of  the  Placenta  in  Advanced  Extrauterine  Abdominal  Pregnancy," 
Obstetrics,  1899,  i,  70-90. 

Bandel:  "Ein  Fall  von  Eierstocksschwangerschaft,"  Beitrage  z.  klin.  Chir.,  xxxvi,  1902, 
657-63. 

Bard:  "A  Case  of  Extrauterine  Foetus,"  Medical  Observations  and  Inquiries  by  a  Society  of  Phy- 
sicians in  London,  1764,  ii,  369-72. 

Beck:  "Ectopic  Pregnancy  Twice  in  the  Same  Patient,  the  Second  Time  Complicated  by  Intes- 
tinal Obstruction,"  Amer.  Jour,  of  Obst.,  1893,  xxvii,  570-576. 

Benicke:    "Ovarialschwangerschaft,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1879,  iv,  276-82. 

Berkeley  and  Bonney:  "Tubal  Gestation;  a  Pathological  Study,"  Jour.  Obst.  and  Gyn.  Brit.  Em- 
pire, 1905,  vii,  77-96. 


174  EXTRAUTERINE  PREGNANCY. 

Bichat :    "Contribution  a  I'etude  de  la  grossesse  gemellaire  intra-  et  extrauterine,"  Revue  de  gyn. 

et  de  chir.  abd.,  1903,  vii,  412-36. 
Boesebeek:   "Ein  Beitrag  zur  Ovarialgraviditat,"  Monatsschr.  f.  Geb.  u.  Gyn.,  1904,  xx,  613-33. 

(Ergiingungshef  t . ) 
von  Both:    " Rechtsseitige  Tubarschwangerschaft.     Ruptur  im  5.  Monat,  Entbindung  des  frei  in 

der  Bauchhohle  lebenden  Kindes  durch  Laparotomie  im  8  Monat,"  Monatsschr.  f.  Geb.  u. 

Gyn.,  1899,  ix,  782-794. 
Bouilly:    "Notes  sur  la  grossesse  extra-uterine  tirees  de  I'analyse  de  cinquante  observations  per- 

sonelles,"  La  Gynecologic,  1898,  iii,  1-16. 
Breslau:    "Zur  Aetiologie  und  path.  Anatomic  der  Extrauterinschwangerschaft,"  Monatsschr.  f. 

_  Geburtsh.,  1863,  xxi.  Supplement  Heft,  119-124. 
Brossi:  Quoted  by  Sanger,  1895. 

Browne:   "A  Contribution  to  the  History  of  Combined  Intrauterine  and  Extrauterine  Twin  Preg- 
nancy," Trans.  Amer.  Gyn.  Soc,  1882,  vi,  444-462. 
Campbell:    "Abhandlung  iiber  die  Schwangerschaft  ausserhalb  der  Gebarmiitter."     Translated 

from  the  English  by  Dr.  Ecker,  Karlsruhe  u.  Freiburg,  1841,  p.  160. 
Cazeaux:   "Des  modifications  de  la  muqueuse  uterine  au  cours  de  revolution  des  grossesses  ecto- 

piques,"  Ann.  de  gyn.  et  d.  obst.,  1904,  i,  2me  ser.,  85-103. 
Chiari:   "Beitrage  zur  Lehre  von  der  Graviditas  tubaria,"  Zeitschr.  f.  Heilk.,  1887,  viii. 
Christer-Nilsson :  "Ueber  gleichzeitige  extra-  und  intra-uterine  Schwangerschaft,"  Mitthl.  a.  d.  gyn. 

Klinik  des  Prof.  Engstrom,  1903,  iv,  1-76. 
Coe:   "Internal  Migration  of  the  Ovum,"  etc..  Trans.  Amer.  Gyn.  Soc,  1893,  268-281,  xviii. 
Conrad  and  Langhans:    "Tubensbhwangerschaft.     Ueberwanderung  des  Eies,"  Archiv  f.  Gyn., 

1876,  ix,  337-359. 
Cornil:    "Sur  I'anatomie  et  I'histologie  de  la  grossesse  tubaire,"  Revue  de  gyn.  et  de  chir.  abd., 

1900,  iv,  3-28. 
Couvelaire:   "Note  sur  I'anatomie  de  la  refleche  dans  la  grossesse  tubaire,"  Comptes  rendus  de  la 

soc.  I'obst.  de  gyn.  et  de  paed.  de  Paris,  1900,  ii,  50-61. 
Couvelaire:  "  Etudes  anatomiques  sur  les  grossesses  tubaires,"  These  de  Paris,  1901. 
Cragin:    "The  Treatment  of  Full-term  Ectopic  Gestation,"  Am.  Jour.  Obst.,  1900,  xh,  740-750. 
Croft:  "An  Anomalous  Case  of  Ectopic  Pregnancy,  Probably  Ovarian,"  Trans.  London  Obst.  Soc, 

1900,  xlii,  316-23. 
CuUingworth:   "Effusion  of  Blood  into  the  Fallopian  Tubes,"  St.  Thomas'  Hospital  Reports,  1893, 

xxi. 
CuUingworth:  "An  Address  on  Tubal  Gestation  with  Special  Reference  to  its  Early  Diagnosis  and 

Treatment,"  The  Clinical  Jour.,  Dec.  8,  1897. 
Dakin:    "Cast  from  the  Uterus  Having  all  the  Characters  of  the  Decidual  Membrane  Formed  in 

Connection  with  Ectopic  Gestation,  together  with  a  Small  Ovarian  Cyst  from  the  Same 

Case,"  etc..  Trans.  London  Obst.  Soc,  1897,  xxxviii,  385-388. 
de  la  Faille:    "Ueber  einen  Fall  von  Graviditas  tubo-uterina,"  Monatsschr.  f.  Geburtsk.,  1868, 

xxxi,  459-64. 
Dezeimeris:   "Grossesses  extra-uterine,"  Journ.  des  conn,  med-chir.,  Dec,  1836. 
Dibot:   Quoted  by  Saenger,  Monatsschr.  f.  Geb.  u.  Gyn.,  1895,  i,  21-28. 
Dobbert:    "Beitrage  zur  Anatomic  der  Uterusschleimhaut  bei  cktopisches   Schwangerschaft," 

Archiv  f.  Gyn.,  1894,  xlvii,  224-242. 
Doche:    "De  la  grossesse  ovarienne,"  These  de  Lyon,  1902. 
Doran:    "Interstitial  or  Tubo-uterine  Gestation,  with  Notes  on  Similar  Cases  in  the  Museums  of 

London  Hospitals,"  Trans.  London  Obst.  Soc,  1882,  xxiv,  227-238. 
Dorland:    "Repeated  Extrauterine  Pregnancy,"  Amer.  Jour,  of  Obst.,  1898,  xxxvii,  478-491. 
Diihrssen:    "Ueber  operative   Behandlung,  insbesondere  die   vaginale  Coeliotomie  bei  Tuben- 

schwangerschaft,    nebst    Bemerkungen    zur    Aetiologie    der    Tubarschwangerschaft    und 

Beschreibung  eines  Tubenpolypen,"  Archiv  f.  Gyn.,  1897,  liv,  207-323. 
Duncan:  "Rupture  of  a  Tubal  Pregnancy  Nineteen  Days  after  Conception,"  Brit.  Gyn.  Jour., 

1904,  XX,  1-11. 
Eden:  A  Decidual  Cast  of  the  Uterus  from  a  Case  in  which  there  was  no  Evidence  of  Extrauterine 

Gestation,"  Trans.  London.  Obst.  Soc,  1897,  xxxix,  132-34. 
Emanuel:  "Eine  20  Jahre  getragene  Extra-uterinschwangerschaft,"  Centralbl.  f.  Gyn.,  1894,  1306. 
Ercolani:    "  Delia  struttura  anatomica  della  caduca  uterina  nei  casi  di  gravidanzi  extrauterina," 

Bologna,  1874. 
Fehling:   "JDie  Bedcutung  der  Tubenruptur  und  des  Tubaraborts  fiir  Verlauf,  prognose  und  Ther- 

apie  der  Tubenschwangerschaft,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1898,  xxxviii,  67-100. 
Fellner:    "Zur  Frage  der  Divertikeleinbettung  in  der  Tube,"  Miinch.  mcd.  Wochenschr.,  1903, 

1,  1893. 
Fellner:   "Ueber  das  Verhalten  der  Gefasse  bei  Eileiterschwangerschaft.    Autothrombose,"  Arch. 

f.  Gyn.,  1905,  Ixxiv,  481-512. 
Frank:    "Ueber  Extrauterinschwangerschaft  mit  besonderer  Beriicksichtigung  der  Ovarialgravi- 
ditat," Centralbl.  f.  Gyn.,  1895,  545. 
Fraenkel:  "Untersuchungen  iiber  die  Decidua  circumflexa  und  ihr  Vorkommen  bei  Tubenschwan- 
gerschaft," Archiv  f.  Gyn.,  1894,  i,  139-188. 
Fraenkel:   " Placentarpolypen  der  Tube,"  Archiv  f.  Gyn.,  1898,  Iv,  714-728. 


LITEEATURE.  175 

Franque  u.  Garkisch:  "Beitrage  zur  ektopischen  Schwangerschaft,"  Zeitsclir.  f.  Heilkunde,  1905, 

xxvi,  274-301. 
Franz:  "Ueber  Einbettung  und  Wachstum  des  Eies  im  Eierstock,"  Beitrage  z.  Geb.  u.  Gyn.,  1902 

vi,  70-81. 
Freund:    "Ueber  die  Indicationen  zur  operativer  Behandlung  erkrankter  Tuben,"  Volkmann's 

Sammlung  klin.  Vortrage,  1888,  Nr.  323. 
Freund:    "Beitrage  zur  Anatomie  der  ausgetragenen  Extrauteringraviditat,"  Beitrage  z.  Geb. 

u.  Gyn.,  1903,  104-137. 
Funck-Brentano:   "Des  grossesses  uterines  survenant  apres  la  grossesse  extra-uterine," These  de 

Paris,  1898. 
Fiith:    "Studien  liber  die  Einbettung  des  Eies  in  der  Tube,"  Monatssclir.  f.  Geb.  u.  Gyn.,  1898, 

590-613. 
Fiith:   "Ueber  Ovarialschwangerschaft,"  Beitrage  z.  Geb.  u.  Gyn..  1902,  vi,  314-31. 
Fiith:   "Ueber  das  Vordringen  des  Chorion  laeve  in  die  Tubenschleimhaut,"  etc.     Archiv  f.  Gyn., 

1904,  bixii,  394-409. 
Geuer:    "Ovarialschwangerschaft,"  Centralbl.  f.  Gyn.,  1894,  391. 
Gilford:    "Ovarian  Pregnancy,"  Brit.  Med.  Jour.,  1901,  ii,  96.3-64. 

GHtsch:   "Zur  Aetiologie  der  Tubenschwangerschaft,"  Archiv  f.  Gyn.,  1900,  Ix,  385-425. 
Goebel:    "Beitrag  zur  Anatomie  und  Aetiologie  der  Graviditas  tubaria  an  der  Hand  eines  Pra- 

partes  von  Tubarmole,"  Archiv  f.  Gyn.,  1898,  Iv,  658-713. 
Gottschalk:  "Ein  Praparat  von  Ovarialschwangerschaft  aus  der  3.-4.  Woche  der  Graviditiit," 

Centralbl.  f.  Gyn.,  1886,  727. 
Gottschalk:    "Ein  Lithokelyphopiidion  das  gleichzeitig  als  Fall  von  reiner  Eierstocksschwanger- 

schaft  sehr  bemerkenswerth  ist,"  Verhandlungen  der  deutschen  Ges.  f.  Gyn.,  1893,  304-5. 
Gottschalk:    "Eierstocksschwangerschaft,"  Zeitschr.  f.  Geb.  u.  Gjti.,  1902,  Ixvii,  487. 
Granville:      "Graphic    Illustrations    of     Abortion    and    Diseases    of    Menstruation,"    London, 

1834. 
Griffiths:   "Note  on  the  Importance  of  a  Decidual  Cast  as  Evidence  of  Extrauterine  Gestation," 

Trans.  London  Obst.  Soc,  1894,  xxxvi,  335-340. 
Griffiths:    "Gestation  in  the  Fallopian  Tube,  and  the  Structural  Changes  that  take  Place  within 

its  Walls,"  Jour,  of  Path,  and  Bacteriology,  1898,  v,  44.3-459. 
Gubb:   "The  Placenta  in  Ectopic  Gestation  and  its  Growth  after  the  Death  of  the  Foetus,"  Med. 

Press  and  Circular,  1894,  Ivii,  326. 
Gurgui:    "Die  Ovarialschwangerschaft  vom  path.  anat.  Standpunkte,"  Stuttgart,  1880,  p.  150. 
Gutzwiller:    "Ein  Fall  von  gleichzeitiger  Extra-  and  intrant eringraviditat.     Zusammenstellung 

und  Betrachtung  derartiger  Falle,"  Archiv  f.  Ciyn.,  1893,  xliii,  223-251. 
Harbert:    "A  Case  of  Extrauterine  Pregnancy,"  Western  Jour,  of  Med.  and  Surg.,  1849,  3d  ser., 

iii,  110-113. 
Hart:   "  Minute  Anatomy  of  the  Placenta  in  Extrauterine  Gestation,"  EdinburghMed.  Jour.,  1889, 

xxxv,  344-47. 
Hart:    "On  the  Extraperitoneal  Form  of  Extrauterine  Gestation,"  Amer.  Jour,  of  Obst.,  1894, 

xxix,  577-593. 
Hart:   "On  the  Alleged  Growth  of  the  Placenta  in  Extrauterine  Gestation  after  the  Death  of  the 

Foetus,"  Amer.  Jour,  of  Obst.,  1892,  xxv,  721-735. 
Hart  and  Carter:   "A  Contribution  to  the  Sectional  Anatomy  of  Advanced  Extrauterine  Gesta- 
tion," Edinburgh  Med.  Jour.,  1887,  xxxiii,  332-343. 
Harris:   "Operation  of  Primary  Laparotomy  in  Cases  of  Extrauterine  Pregnancy  with  a  Tabular 

Record  showing  the  Results  in  Twenty-seven  Women  under  Twenty-six  Operations,"  Amer. 

Jour.  Obst.,  1887,  xx,  1154-67. 
Harris:    "Weitere  Fortschritte  der  Entbindung  ektopischer  lebensfiihriger  Friichte  durch  Koeli- 

otomie,"  Monatssclir.  f.  Geb.  u.  Gyn.,  1897.  vi,  137-156. 
Haydon:   "Case  of  Extrauterine  Foetation,  in  which  Two  Foetuses  were  found  in  Connection  with 

the  Same  Tube."  Trans.  London  Obst.  Soc,  1864,  v,  280-283. 
Hecker:     "Beitrage   zur   Lehre   von   der   Schwangerschaft   ausserhalb   der   Gebarmutterhohle," 

Monatsschr.  f.  Gebk.,  18.59,  xiii,  81-123. 
Heikel:   "Xeue  Beobachtungen  wiederholter  Tubenschwangerschaft  bei  derselben  Frau,"  Mitthl. 

a.  d.  gyn.  Klinik  des  Prof.  Engstrom.  1903,  iv,  77-99. 
Hein:    "Eierstocks-schwangerschaft,"  Archiv  f.  path.  Anat.,  1847,  i.  51-3-537. 
Heinsius:    "Ueber  die  Beziehungen  zwischen  kindlichen  u.  miitterlichen  Elementen  bei  ektopi- 
schen Graviditat,"  Zeitschr.  f.  Geb.  u.  Gyn..  1905,  Uv,  198-209. 
Hennig:   "Die  Krankheiten  der  Eileiter  und  die  Tubenschwangerschaft,"  Stuttgart,  1876. 
Hennigsen:    "Abdominalschwangerschaft    bei  einer    Sechtsgebiirenden,"  Archiv  f.   Gjn.,  1870, 

i,  335-340. 
Henrotin:    "Vaginal  Section  for  Extrauterine  Pregnancy,"  Amer.  Gyn.  and  Obst.  Jour.,  1890, 

ix,  151-160. 
Henrotin:  "Practice  of  Obstetrics,  by  American  Authors,"  Philadelphia,  1899.  p.  386.  ^^ 

Henrotin  and  Herzog:    "Anomalies  du  canal  de  Muller  comme  cause  de  grossesses  ectopiques, 

Rev.  de.  g>-n  et  de  chir.  abd.,  1898,  63.3-649. 
Herman:    "On  Deliverv  by  the  Vagina  in  Extrauterine  Gestation,"  Trans.  London  Obst.  boc, 

1887,  xxix,  429-455. 


176  EXTRAUTERINE  PREGNANCY. 

von  Herff:    "Zur  Technik  der  Entfernung  vorgeriickter  Extrauterinschwangerschaften,"  Zeit- 

schr.  f.  Geb.  u.  Gyn.,  1896,  xxiv,  12-39. 
Herzfeld:    "Ueber  einen  Fall  von  Ovarialgraviditat,  uterine  Schwangerschaft.     Laparotomie. 

Heilung,"  Wien.  klin.  Wochenschr.,  1891,  No.  43,  802-804. 
Hitschmann  and  Lindenthal:    "Ueber  die  Haftung  des  Eies  an  atypischen  Orten,"  Zentralbl. 

f.  Gyn.,    1903,  263-75. 
Hoohne-   "Zn-  Frage  der  Entstehung  intramuscularen  Abzweigungen  des  Tubenlumens,"  Archiv 

t.  Gyn.,  1905,  Ixxiv,  1-46. 
Hofmeier:    "Zur  Kenntniss  der  normalen  Uterusschleimhaut,"  Centralb.  f.  Gyn.,  1893,  764-66. 
Hofmeier:    "Anat.  und  klin.  Beitrage  zur  Lehre  ectopischer  Schwangerschaft,"  Wurzburg,  1894. 
Hofmeier:     "Wiederholte   Schwangerschaft   in   derselben   Tube,"    Berliner   klin.    Wochenschr., 

1905,  847-49. 
Hoist:   "Graviditas  extrauterine  mit  Eklampsie,"  Ref.  Centralbl.  f.  Gyn.,  1898,  487. 
Hugenberger:    Bericht  aus  der  Hebammen  Institut  in  Moskau.  St.  Petersburg,  1863,  122. 
Jacobs:  "Notes  cliniques  sur  82  cas  de  grossesse  tubaire,"  Ann.  de  gyn. et  d'obst.,  1903,  Ix,  268-73. 
Janot:   "De  I'oviducte  chez  la  femme;   ses  modifications  pendant  la  grossesse  uterine,"  These  de 

Lyon,  1898. 
Janvrin:    "A  Case  of  Tubal  Pregnancy  of  Unusual  Interest,"  Trans.  Amer.  Gyn.  Soc,  1886, 

xi,  471-484. 
Jayle  and  Naudrot:    "La  grossesse  tubaire  bilaterale,"   Revue   de  gyn.  et  de   chir.  abd.,  1904, 

viii,  195-226. 
Kantorowicz:    "Eierstocksschwangerschaft,"  Volkmann's   Sammlung   klin.  Vort rage,  1904,  Nr. 

370. 
Kehrer:    "Das  Nebenhorn  des  doppelten  Uterus,"  Heidelberg,  1900. 
Keller:   "Zur  Diagnose  der  Tubengraviditat,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1890,  xix,  1-24. 
Kelly:    "The  Treatment  of  Extrauterine  Pregnancy  Ruptured  in  the  Early  Months  by  Vaginal 

Puncture  and  Drainage,"  Trans.  Amer.  Gyn.  Soc,  1896,  xxi,  190-209. 
Kermauner:    "Beitrage  zur  Anatomic  der  Tubenschwangerschaft,"  Berlin,  1904. 
Kieser:   "Das  Steinkind  von  Leinzell,"  D.  I.  Tubingen  1854. 

King  John:  "An  Analysis  of  the  Subject  of  Extrauterine  Gestation,"  Norwich,  1818,  p.  176. 
Kiwisch:  Klinische  Vortrage,  Prag,  1852,  ii,  238-243. 

Klein:  "Zur  Anatomie  der  schwangeren  Tube,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1890,  288-306. 
Kouwer:    "Fall  von  Schwangerschaft  im  Graaf-schen  Follikel,"  Centralbl.  f.  Gyn.,  1897,  1429. 
Kreisch:    "Beitrag  zur  Anatomie  und  Pathologic  der  Tubargraviditiit,"  Monatsschr.  f.  Geb.  u. 

Gyn.,  1899,  ix,  794-812. 
Kromer:   " Untersuchungen  iiber  die  tubare  Eieinbettung,"  Archiv.  f.  Gyn.,  1903,  Ixviii,  57-108. 
Krusen:  "Triple  Ectopic  Gestation,"  Amer.  Medicine,  1902,  iii,  18-19. 
Ktichenmeister:    "Ueber  Lithopadien,"  Archiv  f.  Gyn.,  1881,  xvii,  153-359. 
Kiihne:  "Beitrag  zur  Anatomie  der  Tubenschwangerschaft,"  Marburg,  1899. 
Kussmaul:    "Von  dem  Mangel,  der  Verkiimmerung  und  Verdopplung  der  Gebarmutter,"  Wiirz- 

burg,  1859. 
Ktistner-     "Der    Fick'sche    Fall    von    Abdominalschwangerschaft — eine     Eierstocksschwanger- 
schaft," Verh.  d.  deutschen  Gesell.  f.  Gyn.,  1890,  213-334. 
Kiistner:     "tFeber  Extrauterinschwangerschaft,"  Volkmann's   Sammlung  klin.  Vortrage,   1899, 

N.  F.,  Nr.  244-245. 
Landau  and  Rheinstein:    "Beitrage  zur  pathologischen  Anatomie  der  Tube,"  Archiv  f.  Gyn., 

1891,  xxxix,  273-290. 
Lange:  "Beitrage  zur  Frage  der  Decidualbildung  in  der  Tube,"  etc.,  Monatsschr.  f.  Geb.  u. 

Gyn.,  1902,  xv,  48-71. 
Larsen:  See  Tainturier  and  Eichmiiller. 
Leopold:     "Tubenschwangerschaft   mit   ausserer   Ueberwanderung   des  Eies  und   consecutiver 

Haematocele  retrouterine,"  Archiv  f.  Gyn.,  1876,  x,  248-269. 
Leopold:    "Zur  Lehre  von  der  Graviditas  interstitialis,"  Archiv  f.  Gyn.,  1878,  xiii,  355-65. 
Leopold:    " Experimentelle  Untersuchungen  iiber  das  Schicksal  implantirter  Foten,"  Archiv  f. 

Gyn.,  1881,  xviii,  53-80. 
Leopold:"  " Ovarialschwangerschaf t  mit  Lithopadionbildung  von  35  jahriger  Dauer,"  Archiv  f. 

Gyn.,  1882,  xix_,  210-218. 
Leopold:    " Ausgetragene  secundiire  Abdominalschwangerschaft  nach  Ruptura  uteri  traumatica 

im  4  Monat.  Laparotomie.  Genesung,"  Archiv  f.  Gyn.,  1896,  Hi,  376-388. 
Leopold:     "Beitrag    zur    Graviditas    extrauterina.     1.  Graviditas    interstitialis. — 2.  Graviditas 

auf  der  Fimbria  ovarica  bez.     Plica  infundibulo-ovarica. — 3.  Graviditas  ovarialis,"  Arch. 

f.  Gyn.,  1899,  Iviii,  526-565. 
Leopold:   "  Beitrag  zur  Graviditas  extra-uterina.    4  Die  Graviditas  tubo-ovarialis,"  Arch.  f.  Gyn., 

1899,  lix,  557-594. 
Lescuyer:  "  De  la  modification  du  placenta  dans  les  grossesses  extrauterine,"  These  de  Nancy,  1898. 
Lindfors:  "Ein  Fall  von  weit  vorgeschrittener  Extrauteringraviditat  mit  Hydramnios,"  etc.,  Cen- 
tralbl. f.  Gyn.,  1902,  xxvi,  711. 
Loschge:    "Archiv.  f.  med.  Erfahrung,"  etc.,  1818. 
Lockyer:  "A  Case  of  Incomplete  Tubal  Abortion  showing  Intramural  Imbedding  of  the  Ovum," 

Trans.  London  Obst.  Soc,  1903,  xlv,  191-196. 


LITERATURE.  177 

Ludwig:  " Eierstocksschwangerschaf t  neben  normaler  uteriner  Schwangerschaft,"  etc.,  Wien. 
klin.  Wochenschr.,  1896,  600-604. 

Lumpe:  "Ein  Beitrag  z.  Kasuistik  der  Eierstocksschwangerschaft,"  Monatsschrift  f.  Geb.  u.  Gyn., 
1902,  XV,  1-9. 

Lust:  "The  Desirability  of  the  Early  Performance  of  Laparotomy  in  Cases  of  Abdominal  Preg- 
nancy," Brit.  Med.  Jour.,  1886,  1083-90. 

Mandl:  "Ueber  den  feineren  Bau  der  Eileiter  wahrend  und  ausserhalb  der  Schwangerschaft," 
Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  v,  Ergangungsheft,  130-139. 

Mandl:  "Ueber  die  Richtung  der  Flimmerbewegung  im  menschUchen  Uterus,"  Centralbl.  f.  Gyn., 
1898,  No.  13,  323-28. 

Mandl  and  Schmidt:  "Beitrage  zur  Aetiologie  und  pathologischen  Anatomic  der  Eileiter- 
schwangerschaften,"  Archiv  f.  Gyn.,  1898,  401-487. 

Mann:  "Specimen  of  Ovarian  Pregnancy,"  Trans.  Amer.  Gyn.  Soc,  1888,  350-1. 

Martin:  "Ein  Fall  von  Ovarialschwangerschaft  mit  Carcinoma  colli  uteri,"  Zeitschr.  f.  Geb.  u. 
Gyn.,  1892,  xxiii,  179. 

Martin:  "Ueber  ektopische  Schwangerschaft,"  Berl.  klin  Wochenschr.,  1893,  513-515,  544-547, 
and  568-572. 

Martin:  "Zur  Kenntniss  der  Tubenschwangerschaft,"  Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  1-7  and 
244-246. 

Martin  and  Orthmann:  "Eileiterschwangerschaft,"  "Die  Krankheiten  der  Eileiter"  von  A.  Mar- 
tin, Berlin  and  Leipzig,  1895,  303-399. 

Matwejew  u.  Sykow:    "Blasenmole  in  der  Tube,"  Centralbl.  f.  Gyn.,  1902,  296. 

Mayer:   "Kritik  der  Extrauterinalschwangerschaft."  etc.,  Giessen,  1845. 

Mendes  de  Leon  et  HoUeman:  "De  la  grossesse  ovarienne,"  Revue  de  gyn.  et  de  chir.  abd.,  1902, 
vi,  387-400. 

Mercerus:  Quoted  by  Webster. 

Mikolitsch:  "Zur  Aetiologie  der  Tubenschwangerschaft,"  Zeitschr.f.  Geb.u.  Gvn.,  1903,  xlix,  42-62. 

Micholitsch:    "Ueber  Ovarialgraviditat,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1903,  xlix,  508-22. 

Moericke:  "Zur  Aetiologie  der  Tuben-graviditiit,"  Sammlung  zwangloser  Abhandlungen  a.  d. 
Gebiete  der  Frauenheilkunde  und  Geb.,  1900,  iii.  Heft  4,  5. 

Moseley:  "Twin  Pregnancy;  One  Foetus  being  Intrauterine  and  the  Other  Extrauterine,"  Amer. 
Jour,  of  Obst.,  1896,  xxiii,  682-689. 

Noble:    "Remarks  on  Ectopic  Pregnancy,"  Amer.  Gyn.  and  Obst.  Jour.,  1895,  vi,  167-171. 

Oliver:  "Ovarian  Pregnancy,"  Lancet,  1896,  ii,  241. 

Opitz:  "Ueber  die  Ursachen  der  Ansiedlung  des  Eies  im  Eileiter,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1902, 
xlviii,  1-39. 

Orthmann:  "Ueber  Tubenschwangerschaften  in  den  ersten  Monaten,  mit  besonderer  Beriick- 
sichtigung  der  path.  anat.  Befunden,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1890,  143-177. 

Orthmann:  "Beitrag  zur  fruhzeitigen  Unterbrechung  der  Tubenschwangerschaft  und  zur  Kennt- 
niss des  weiteren  Schicksals  des  Eies,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1894,  xxix,  61-92. 

Orthmann:  "Zwei  FiiUe  von  sehr  fruhzeitigen  Unterbrechung  einer  Eileiterschwangerschaft, 
nebst  Bemerkungen  zur  Therapie,"  Deutsche  med.  Wochenschr.,  1898,  No.  2,  28-31. 

Osgood:  "A  Remarkable  Extrauterine  Case,"  Med.  Communications  to  the  Massachusetts  Med. 
Soc,  1790-1808,  i.  No.  2,  part  ii,  30-41. 

Ott:    "Beitrage  zur  Kenntniss  der  ektopischen  Formen  der  Schwangerschaft,"  Leipzig,  1898. 

Otto:  "Ueber  Tubenschwangerschaft,  mit  Beriicksichtigung  eines  Falles  von  Graviditas  tubaria 
molaris  hydatidosa,"  D.  I.  Greifswald,  1871. 

Paltauf:    "Die  Schwangerschaft  in  Tubo-ovarialcysten,"  Archiv  f.  Gyn.,  1887,  xxx,  457-470. 

Pantellani:  "Die  mehrfachen  Schwangerschaft  die  Extrauteringraviditaten  und  die  Entwicke- 
lungsanomalien  der  weiblichen  Geschlechtsorgane  vom  anthroprogenetischen  Gesicht- 
spunkte  aus  betrachtet,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1896,  xxv,  373-413. 

Parry:   "Extra-uterine  Pregnancy,"  London,  1876,  p.  276. 

Patenko:  "Zur  Lehre  von  der  Extrauterinschv/angerschaft  (Graviditas  ovarialis),"  Archiv  f. 
Gyn.,  xiv,  1879,  156-164. 

Peters:   "Ueber  die  Einbettung  des  menschlichen  Eies,"  Wien,  1899. 

Petersen:  "Beitrage  zur  path.  Anatomic  der  graviden  Tube,"  Berlin,  1902. 

Pfannenstiel:    "Extrauterine  Graviditat,"  Verh.  d.  deutschen  Gesell.  f.  Gyn.,  1903,  x,  194-199. 

Pilliet:  "Etude  histologique  des  modifications  de  I'uterus  dans  la  grossesse  tubaire,"  Ann.  de 
gyn.  et  d'obst.,  1895,  xliv,  241-269. 

Pinard:  "Nouveaux  documents  pour  servir  a  I'histoire  de  la  grossesse  extra-uteriiie,"  Ann.  de 
gyn.  et  d'obst.,  1892,  xxxviii,  1-11,  99-118,  and  171-188. 

Potocki:  "Sur  une  variete  insolite  de  grossesse  extrauterine  abdominale,"  etc.,  Comptes  rend, 
de  la  soc.  d'obst.  de  gyn.  et  de  paed.  de  Paris,  1902,  iv,  229-242. 

Prochownik:  "Ein  Beitrag  zur  Mekanik  des  Tubenatborts,"  Festschr.  des  Gesellsch.  f.  Geb.  u. 
Gyn.  in  Berlin,  Wien,  1894,  266-295. 

Prochownik:    "Zur  Mechanik  des  Tubenaborts,"  Archiv  f.  Gyn.,  1895,  xlix,  177-241. 

Puech:   "De  la  grossesse  de  I'ovaire,"  Ann.  de  gyn.  et  d'obst.,  1878,  x,  1-20.  ,    r    „  -r* 

Recklinghausen:  " Perforierende  Blasenmole  bei  5  wochenlichen  Tubenschwangerschaft,  Deut- 
sche med.  Wochenschr.,  1889,  709. 

VOL.  II — 12 


178  EXTRAUTERINE  PREGNANCY. 

Risel:    "Zur  Kenntniss  des  primaren  Chorioepithelioms  der  Tube,"  Zeitschr.  f.  Geb.  u.  Gyn., 

1905,  Ixi,  154-189. 
Robson:   "Primary  Ovarian  Gestation,"  Trans.  London  Obst.  Soc,  1902,  xliv,  215-21. 
Rogers:    "Extrauterine  Fetation  and  Gestation  and  the  Early  Signs  which  Characterize  It,"  etc., 

Philadelphia,  1867,  p.  61. 
Rokitansky:    "Extrauterinschwangerschaft,"  Lehrbuch.  der  path.  Anatomie,  1861,  iii,  534-543. 
Rosenthal:    "Ein  Fall  intramuraler  Schwangerschraft,"  Centralbl.  f.  Gyn.,  1896,  1297-1305. 
Runge:    "Beitrag  zur  Aetiologie  der  Extrauteringraviditat,"  Archiv  f.  Gyn.,  1903,  Ixx,  690-722. 
Runge:   "Beitrag  zur  Anatomie  der  Tubargraviditat,"  Archiv  f.  Gyn.,  1904,  Ixvi,  652-674. 
Sanger:    "Graviditas  ovarico-abdominalis.  Litho-kelyphopadion  abdominalis.  Placenta  in  einem 

vollstandig  geschlossenen  Sacke  des  linken  ovarium  und  Lig.  Latum,"  Centralbl.  f.  Gyn., 

1890,  522-524. 
Sanger:   '-'Ueber  einem  Fall  von  ectopischer  Drillingsschwangerschaft,"  Centralbl.  f.  Gyn.,  1893, 

148. 
Sanger:    "Ueber  solitare  Hamatocele  und  deren  Organisation,"  Verh.  der  deutsch.  Ges  f.  Gyn., 

1893,  281-302. 
Sanger:     "Conception  durch    ein    accessorisches  Tuben-Ostium.     Kaiserschnitt  bedingt    durch 

friihere  ektopische  Schwangerschaft,"  Monatsschr.  f.  Geb.  u.  Gyn.,  1895,  i,  21-28. 
Saxtorph:  Quoted  by  Spiegelberg. 
Schauta:    "Beitrage  zur  Casuistik,   Prognose  und  Therapie  der  Extrauterinschwangerschaft," 

Prag,  1891,  p.  61. 
Schauta:   "Tubarschwangerschaft  mit  Haematommole,"  Zentralbl.  f.  Gyn.,  1903,  1402,  140. 
Schmorl:    "Ueber  grosszellige   (decidua-ahnliche)  Wucherungen  auf  dem  Peritoneum  und  den 

Ovarien  bei  intrauteriner  Schwangerschaft,"  Monatsschr.  f.  Geb.  u.  Gyn.,  1897,  v,  46-50. 
Schober:  "LTeber  Erkrankungen  gewunderer  Tuben,"  D.  I.  Strassburg.  1889. 
von  Schrenck:  "Ueber  ektopische  Graviditiit,"  D.  I.  Dorpat,  1893. 

Segond:   "Traitement  des  grossesses  extra-uterines,"  Annales  de  gyn.  et  d'obst.  1898,  1,  241-316. 
Simon:   "Fall  von  reiner  Ovarialschwangerschaft,"  Centralbl.  f.  Gyn.,  1902,  1379. 
Simpson:  "Coincident  Tubal  and  Extrauterine  Pregnancy,"  Amer.  Jour.  Obst.,  1904,  xlix,  333-55. 
Sippel:    "Zur  Kenntniss  und  Behandlung  der  Tubenschwangerschaft,"  Monatsschr.  f.  Geb.  u. 

Gyn.,  1879,  v,  437-444. 
Spiegelberg:    "Eine  ausgetragene  Tuben-Schwangerschaft,"  Archiv  f.  Gyn.,  1878,  xiii,  73-79. 
Spiegelberg:   "Zur  Casuistik  der  Ovarialschwangerschaft,"  Archiv  f.  Gyn.,  1878,  xiii,  73-79. 
St.  Maurice:  Quoted  by  Webster. 
Stein:  Quoted  by  Funck-Brentano. 
Strauss:    "Tubargraviditat  bei  gleichzeitiger  intrauteriner  Schwangerschaft,"  Zeitschr  f.  Geb. 

u.  Gyn.,  1900,  xliv,  26-38. 
Sutton:    "Tubal  Pregnancy,"  "Surgical  Diseases  of  the  Ovaries  and  Fallopian  Tubes,"  Phila- 
delphia, 1891. 
Sutton:   "On  Some  Cases  of  Tubal  Pregnancy,"  Trans.  Obst.  Soc.  of  London,  1898,  xl,  313-326. 
Sutton:    "The  Purvis  Oration  on  Abdominal  Pregnancy  in  Women,  Cats,  Dogs,  and  Rabbits," 

Lancet,  1904,  ii,  1625. 
Sutton  and  Giles:   "Tubal  Pregnancy,"  "Diseases  of  Women,"  Philadelphia,  1897,  228-249. 
Tainturier:  "Etiologie  de  la  grossesse  ectopique,"  These  de  Paris,  1895. 
Tainturier  et  Eichmuller:    "Grossesse  ovarienne  type.     Laparotomie  Guerison,"  Ann.  de  gyn. 

et  d'obst.,  1894,  xU,  135-141. 
Tait:    "Lectures  on  Ectopic  Pregnancy  and  Pelvic   Hsematocele,"  Birmingham,  1888,  p.  107. 
Taylor:  "Extrauterine  Pregnancy.     A  Clinical  and  Operative  Study,"  London,  1899,  p.  205. 
Thompson:    "Seltene  Falle  von  Extrauteringraviditat,"  Monatsschr.  f.  Geb.  u.   Gyn.,  1899,  ix, 

461-73. 
Thompson:  "Ovarian  Pregnancy  with  Report  of  a  Case,"  Amer.  Gyn.,  1902,  i,  1-15. 
Thorn:    "Ueber  Beckenhamatome,"  Volkmann's  Sammlung  klin.  Vortrage,  N.  F.,  Nr.  119-120. 
Thorn:  "  Grenzen  der  operativen  Therapie  der-Extra-uterinschwangerschaft  und  ihrer  Ausgange," 

Centralbl.  f.  Gyn.,  1898,  p.  1111. 
Toth:   "Beitrage  zur  Frage  der  ektopischen  Schwangerschaft,"  Archiv  f.  Gyn.,  1896,  li,  410-482. 
Tueffel:    "Hydramnion  bei  Extrauterinschwangerschaft,"  Archiv  f.  Gyn.,  1884,  xxii,  57-64. 
Tussenbroek:    "Die  Decidua  uterina  bei  ektopischer  Schwangerschaft,"  Arch.  f.  path.  Anat., 

1893,  cxxxiii,  207-236. 
Tussenbroek:    "Un  cas  de  grossesse  ovarienne  (Grossesse  dans  un  follicule  de  Graaf),"  Ann.  de 

gyn.  et  d'obst.,  1899,  Iii,  537-573. 
Uhde:  "Graviditas  ovarii,"  Monatsschr.  f.  Geburtsk.,  1857,  x,  339-342. 
Veit:  "Die  Eileiterschwangerschaft,"  Stuttgart,  1884. 

Veit:  "Eine  exstirpirte  Tubenschwangerschaft,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1889,  xvii,  335. 
Veit;    "Zur  Behandlung  friiher  Extrauterinschwangerschaft,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1899, 

xl,  151-170. 
Veit:   "Ueber  Deportation  der  Chorionzotten,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1901,  466-504. 
Veit:   "Ueber  die  Anatomie  der  Extrauterinschwangerschaft,"  Verh.  d.  deutschen  Gesellschaft  f. 

Gyn.,  1903,  x,  19-56. 
Veit:  "Die  Verschleppung  der  Chorionzotten,"  Wiesbaden,  1905. 
Velpeau:    "Traite  complet  de  I'art  des  accouchements,"  Paris,  1835,  i,  214. 


TEEATMENT.  179 

Virchow:    "Extrauterinschwangerschaft,"  "Gesammelte  Abhandlungen  zur  wissenschaftlichen 

Medicin,"  Frankfort,  1856,  790^812. 
Voigt;    " Schwangerschaft  auf  der   Fimbria  ovarica,"  Monatsschr.  f.  Geb.  u.  Gyn     1898    viii 

222-32. 
Voigt:   "Zur  Bildung  der  Capsularis  bei  der  Tubarschwangerschaft,"  Arcliiv  f.  Gyn.    1903   Ixviii 

642-60. 
Voigt:   "Zur  Bildung  der  intervillosen  Riiume,"  etc.,  Zeitschr.  f.  Geb.  u.  Gyn.,  1904.  li,  557-578. 
Waldeyer:    "Ueber  eine  ectopische  Schwangerschaft  bei  einem  Mantelpavian,"  Zeitschr  f   Geb 

u.  Gyn.,  1893,  xxvii,  177. 
Wallgren:  "  Zur  mikroscopischen  Anat.  der  Tubenschwangerschaft  beim  Menschen,"  Anatomische 

Hefte,  1905,  xxvii,  359-377. 
Walker:   "Der  Bau  der  Eihaute  bei  Graviditas  abdominalis,"  Archiv  f.  path.  Anat.  und  Physiol 

1887,  cvii,  72-90. 
Walter:    "Einige  Beobachtungen  uber  Schwangerschaft  ausserhalb  der  Gebarmiitter.     (Primjire 

Eierstocksschwangerschaft),"  Monatschr.  f.  Geburtsk.,  1861,  xviii,  171-203. 
Webster:    "Tubo-Peritoneal  Ectopic  Gestation,"  Edinburgh  and  London,  1892,  p.  50. 
Webster:  "Ectopic  Pregnancy,"  Edinburgh  and  London,  1895. 

Webster:   "Study  of  a  Specimen  of  Ovarian  Pregnancy,"  Am.  Jour.  Obst.,  1904,  1,  28-44. 
Weil:    "Ueber  wiederholte  Eileiterschwangerschaft,"  Prager  med.  Wochenschr.,  1899,  Nos.  1,  2, 

and  3. 
Weinbrenner:    "Ueber  interstitielle  Schwa^ngerschaft,"  Zeitschr.  f.  Geb.  u.  Gyn.,  1904,  li,  57. 
Werth:   "Beitrage  zur  Anatomie  u.  zur  operative  Behandlung  der  Extrauterinschwangerschaft  " 

Stuttgart,  1887. 
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1905,  xxii,  739-771. 
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Amer.  Jour,  of  Med.  Sciences,  Oct.,  1891. 
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lung  klin.  Vortriige,  1890,  Nr.  3. 
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ii,  298-321. 
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xli,  1-61. 


CHAPTER  XXXI. 

DISEASES  OF  THE  FEMALE  BREAST, 

By  J.  C.  Bloodgood,  M.D. 

INTRODUCTION. 

This  contribution  is  based  upon  a  clinical  and  pathologic  study  of  1048  lesions 
of  the  female  breast  which  have  been  observed  in  the  surgical  pathologic  laboratory 
of  the  Johns  Hopkins  Hospital  and  University.  The  majority  of  patients  were 
treated  in  the  surgical  clinic  of  Professor  Halsted. 

When  comparative  figures  as  to  results  are  given,  only  the  cases  admitted  to  the 
Johns  Hopkins  Hospita]  surgical  wards  are  considered. 

The  "problem  in  the  treatment  of  every  lesion  of  the  female  breast  is  the  early  recog- 
nition of  carcinoma  and  its  removal  by  the  so-called  complete  Halsted  operation. 

In  females  under  twenty-five  years  of  age  the  probabilities  are  that  every  single 
tumor  in  the  breast  is  benign.  It  is  safe,  therefore,  to  consider  a  tumor  in  a  woman 
under  twenty-five  benign  until  it  is  proved  to  be  malignant.  On  the  other  hand, 
every  single  tumor  in  the  breast  of  a  woman  over  twenty-five  should  be  considered 
malignant  until  it  is  proved  to  be  benign. 

The  public  should  be  educated  to  know  that  cancer  of  the  breast  is,  in  its  onset, 
a  local  disease  curable  by  a  complete  excision;  that  many  palpable  masses  in  the 
breast  are  not  cancer  and  can  be  removed  without  loss  of  the  breast  and  without 
mutilation.  If  women  can  be  educated  to  seek  advice  the  moment  their  attention 
is  called  to  a  tumor  in  the  breast,  to  a  discharge  from  the  nipple,  to  any  change  in 
the  skin  or  nipple,  then  all  lesions  can  be  subjected  to  proper  treatment  at  a  period 
most  favorable  for  the  cure  of  cancer  and  for  the  removal  of  non-malignant  tumors 
without  mutilation. 

Clinically  all  lesions  of  the  breast  can  be  divided  into  two  groups:  the  first. 
clinically  malignant;  the  second,  clinically  doubtful.  When  the  surgeon  is  able, 
from  the  clinical  history  and  examination,  to  recognize  a  cancer  of  the  breast,  he 
should  proceed  at  once  with  the  complete  operation.  The  pathology  of  the  tumor 
is  subjected  to  examination  only  after  its  removal.  On  the  other  hand,  when  it  is 
impossible  to  conclude  that  the  tumor  is  malignant,  one  is  not  justified  in  doing  the 
complete  operation  without  a  positive  diagnosis.  This  can  be  done  only  by  explor- 
ing the  palpable  mass  with  the  knife  and  deciding  the  nature  of  the  tumor  from  the 
gross  appearance  or  a  rapid  frozen  section  (preferably  the  former).  If  it  is  malig- 
nant, the  wound  is  cauterized,  closed,  and  the  complete  operation  performed.     If 

180 


INTRODUCTION.  181 

the  tumor  is  not  malignant,  one  removes  the  tumor,  the  entire  breast,  or  both  breasts, 
according  to  the  nature  of  the  benign  lesion  and  the  condition  of  the  surrounding 
breast. 

During  the  age  in  which  cancer  of  the  breast  is  observed  practically  every  benign 
lesion  may  appear.  For  this  reason,  as  long  as  a  tumor  of  the  breast  has  not  assumed 
the  clinical  picture  of  malignancy  any  benign  lesion  is  possible.  The  earlier  women 
seek  advice  after  the  onset  of  the  first  symptom  of  a  disease  of  the  breast,  the  more 
frequently  tumors  will  be  observed  by  surgeons  in  that  state  in  which  a  diagnosis 
can  be  made  only  at  the  exploratory  incision. 

My  own  experience  demonstrates  that  if  the  exploratory  incision  into  such  early 
carcinoma,  clinically  doubtful,  is  follotved  immediately  by  the  complete  operation,  the 
probabilities  of  a  cure  are  not  diminished. 

From  my  observations  on  specimens  sent  to  the  surgical  pathologic  laboratory 
every  patient  has  succumbed  to  carcinoma  if  at  the  first  operation  only  the 
malignant  tumor  was  removed,  and  then  later,  after  a  microscopic  diagnosis,  the 
complete  operation  was  performed. 

It  is  the  object  of  a  contribution  of  this  character  to  confine  itself  strictly  to  the 
two  great  practical  problems :  first,  the  clinical  picture  which  will  allow  a  diagnosis 
of  carcinoma,  and  justify  the  complete  operation  without  an  exploratory  incision; 
second,  to  give  a  clear  description  of  the  gross  appearances  of  the  benign  and  malig- 
nant lesions  of  the  breast,  so  that  they  can  be  recognized  at  the  exploratory  incision 
when  a  positive  clinical  diagnosis  cannot  be  made. 

Surgeons,  therefore,  must  be  their  own  pathologists.  At  the  present  time,  in 
the  majority  of  surgical  clinics,  a  clinical  diagnosis  of  cancer  can  be  made  in  90  per 
cent,  of  cases.  The  gross  appearance  of  a  malignant  tumor  in  the  breast  which  can- 
not be  diagnosed  clinically  does  not  differ  at  all  from  the  tumor  which,  on  account 
of  its  infiltration,  has  assumed  the  picture  which  allows  of  a  clinical  diagnosis.  For 
this  reason  surgeons  will  have  at  least  nine  opportunities  to  familiarize  themselves 
w^ith  the  fresh  appearance  of  cancer  after  the  complete  operation  has  been  per- 
formed, and  so  be  prepared  for  the  one  case  in  which  an  exploratory  incision  must 
be  done.  As  the  majority  of  benign  tumors  occur  in  women  under  twenty-five,  at 
an  age  in  which  cancer  is  almost  unique,  surgeons  will  have  an  opportunity  to  learn 
the  fresh  appearance  of  such  innocent  neoplasms,  and  thus  be  prepared  to  recognize 
them  when  they  are  met  with  at  the  exploratory  incision  into  the  breast  of  an  older 
woman. 

I  feel  quite  certain  that,  in  the  great  majority  of  cases,  this  differential  diagnosis 
is  not  diflScult.  There  are  exceptions  which  require  great  experience.  Until  sur- 
geons acquire  this  experience,  I  believe,  the  greatest  good  will  be  accomplished  by 
performing  the  complete  operation  in  all  cases  in  which,  at  the  exploratory  incision, 
the  surgeon  is  unable  to  convince  himself  that  the  tumor  is  benign. 

The  only  harmful  result  of  a  complete  operation  for  a  benign  lesion  is  mutilation, 
while  an  incomplete  operation  for  carcinoma  is  practically  fatal. 


18^ 


DISEASES    OF   THE    FEMALE    BREAST. 


Fig.  431. — Breast  of  Embkyo 
Dissected  to  Show  Ducts 
(Billroth). 


GENERAL  ANATOMIC  AND  HISTOLOGIC  REMARKS. 
The  mammee  may  be  looked  upon  as  specially  developed  glands  of  the  racemose 
variety  from  the  epidermis.     The  breast,  in  its  development  and  life  history,  may 
be  studied  in  the  following  stages :   the  infantile  breast,  puberty  hypertrophy,  lacta- 
tion hypertrophy,  the  normal  breast,  the  senile  breast. 

The  infantile  breast  (Fig.  431)  is  composed  of  a  number  of  branching  ducts 
surrounded  by  loose  connective  tissue;   the  ducts  unite, 
a  certain  number  pass  into  the  nipple,  and  have  open- 
ings through  the  epidermis.     These  ducts  are  lined  by 
cuboidal  epithelium.     The  entire  breast   is  surrounded 
by  subcutaneous  fat.     The   breast,  therefore,  at  birth, 
consists   of  a  nipple   covered   with   epidermis,  differing 
from    normal    skin,    surrounded    by    another    zone    of 
epidermis,  the  areola,  which  later  becomes  pigmented, 
and  branching  ducts  held  together  by  a  loose  connec- 
tive-tissue stroma  surrounded  by  fat. 
Puberty  hypertrophy  is  physiologic.     The  nipple  becomes  larger,  more  vascu- 
lar, and  sensitive;    the  zone  of  areolar  epidermis  wider,  more  pigmented;    and  be- 
neath this  epidermis  special  glands  appear.     From  the  ducts  epithelium-lined  acini 
originate  by  bulbous  outgrowths  (Fig.  432).     In  addition  to  this  epithelial  hyper- 
trophy there  is  a  development  of  new  connective  tissue  about  the  ducts  and  acini — the 
intralobular    stroma.      The    relation    of    this 
stroma  to  the  ducts  and  acini  resembles  that 
of  a  sheath  of  Schwann  to  the  axis-cylinder  of  a 

nerve.     In  this  intralobular  myxomatous  con-  -,; 

nective  tissue  the  principal  lymphatics  and 
blood-vessels  are  situated,  radiating  from  the 
nipple  throughout  the  breast  and  connecting 
the  breast  tissue  with  the  skin  above,  the 
pectoral  fascia,  deeper  structures  of  the  chest 
wall,  chest,  and  axilla. 

The  Normal  Breast. — When  puberty 
hypertrophy  is  established  we  may  look  upon 
the  result  as  the  normal  breast.  Histolog- 
ically (Fig.  433)  there  are  three  important 
structures — the  parenchyma  (ducts  and  acini) ; 

the  intralobular  stroma,  the  envelope  of  the  parenchyma,  and  the  interlobular 
stroma.  The  epithelial  cells  of  the  ducts  and  acini  have  uniform  morphology,  and 
the  basal  cell  is  arranged  definitely  on  a  basement  membrane;  surrounding  this 
there  is  a  narrow  zone  of  intralobular  stroma,  the  parenchyma,  and  this  stroma 
is  arranged  after  a  definite  plan  which  may  be  looked  upon  as  the  architecture  of 
the  normal  breast. 


Fig.    432. 


-Puberty    Hypertrophy, 
AND  Acini  (Billroth). 


Ducts 


GENEKAL   ANATOMIC    AND    HISTOLOGIC    REMARKS. 


183 


The  gross  appearance  of  the  normal  breast  is  quite  characteristic.  If  a  section 
is  made  through  the  breast  from  nipple  to  pectoral  fascia,  one  sees  a  fan-shaped  mass 
of  tissue  separated  from  the  skin  by  a  zone  of  subcutaneous  fat,  except  at  the  nipple. 
This  tissue  is  opaque,  white  in  color.  Projecting  from  its  cut  surface  one  can  make 
out  minute  elevated  dots  of  a  pinkish  color  which  are  arranged  in  groups  (Plate  I, 
Fig.  1) ;  near  the  nipple  cross  and  longitudinal  sections  of  minute  cavities  (ducts)  may 
be  made  out  (Fig.  434),  In  the  breast  of  a  young  woman  after  puberty  one  seldom 
sees  fat  within  the  zone  of  breast  tissue,  and  there  is  no  fat  between  the  base  of  the 
breast  and  the  pectoral  fascia.     The  breast  has  no  distinct  capsule,  but  in  younger 

C 


2#t^' 


B 


A 


Fig.  433. — Normal  Breast. 
A,  parenchyma;  B,  intralobular  stroma;  C,  interlobular  stroma. 


women  the  breast  tissue  is  sharply  circumscribed  from  the  surrounding  fat  and 
the  pectoral  fascia. 

Lactation  Hypertrophy. — Enlargement  of  the  breast  is  observed  in  the  second 
month  of  pregnancy.  At  this  time  the  nipples  become  more  prominent  and  the 
areola  larger  in  area  and  more  pigmented.  A  discharge  from  the  nipple  (colostrum) 
is  observed  in  the  beginning  of  the  third  month.  The  skin  glands  in  the  areola 
(glands  of  Montgomery)  enlarge  about  this  time  and  produce  small,  roundish 
elevations  of  the  epidermis.  Secretion  of  milk  is  not  fully  established  until  after 
the  second  day  of  the  puerperium. 

The  epithelial  hypertrophy  of  the  breast  associated  with  gravidity  probably 


184  DISEASES    OF   THE   FEMALE   BREAST. 

begins  in  the  early  months  of  pregnancy  and  is  fully  developed  at  the  birth  of  the 
child.  The  changes  are  chiefly  an  increase  in  the  number  of  acini  and  the  character- 
istic development  of  each  acinus.     This  epithelial  hypertrophy  is  accomplished  at 


Fig.  434. — Puberty  Htpebtbophy. 
Photograph  from  section  of  alcohol  specimen. 


the  expense  of  the  breast  stroma.  In  the  fully  developed  lactating  breast  (Fig.  435) 
the  interlobular  stroma  has  practically  disappeared.  Each  lobule  is  made  up  of  a 
group  of  acini  surrounded  by  the  intralobular  stroma,  in  which  the  lymphatic  vessels 
and  blood-vessels  are  larger  than  in  the  normal  breast  (Fig.  436).     It  is  important 


Fig.  435. — Lactation  Hypertrophy. 
Photograph  from  section  of  alcohol  specimen:    skin,  breast,  muscle. 

to  remember  that  in  inflammations  of  the  breast  the  first  changes  are  observed  in 
the  intralobular  stroma.  This  is  due  to  the  fact  that  the  lymphatic  vessels  begin  at 
the  nipple  and  follow  the  branching  ducts  to  the  terminal  acini. 


GENERAL   REMARKS   ON  THE   CLINICAL   PICTURE  AND   DIAGNOSIS. 


185 


Senile  Breast. — In  women  whose  breasts  have  not  been  the  seat  of  lactation 
hypertrophy,  senile  changes  take  place  early — between  thirty  and  forty.  This 
parenchymatous  atrophy  is  observed  later  when  the  breasts  have  been  the  seat  of 
one  or  more  lactations. 

The  breasts  in  a  well-nourished  woman  may  retain  their  size.  This  is  due  to  the 
substitution  of  adipose  tissue.  The  chief  atrophy  takes  place  in  the  parenchyma 
and  intralobular  stroma;  with  the  latter  the  lumen  of  the  lymphatic  vessels  and 
blood-vessels  decreases.  In  the  fully  developed  senile  atrophy  one  sees,  radiating 
from  the  nipple  (Fig.  476),  a  few  bands  of  fibrous  tissue  surrounded  by  more  or  less 
fat,  according  to  the  size  of  the  breast.  Microscopically  (Fig.  457),  the  intralobular 
stroma  has  disappeared,  and  here  and  there  in  the  fibrous  interlobular  stroma  one  can 
see  the  remains  of  a  duct  or  acinus  lined  by  epithelial  cells  which  are  very  much  smaller 
than  normal,  take  the  stain  faintly,  and 
may  have  lost  their  arrangement  on 
the  basement  membrane. 

GENERAL  REMARKS  ON  THE  CLIN- 
ICAL PICTURE  AND  DIAGNOSIS. 

I  have  divided  breast  lesions  into 
two  groups.  In  the  first,  one  is  able, 
from  the  history  and  examination, 
to  make  a  diagnosis  of  a  malignant 
tumor  {clinically  malignant  tumors). 

In  the  second  group,  one  is  unable 
to  make  such  a  diagnosis,  and  an  ex- 
ploratory incision  is  indicated  to  es- 
tablish the  nature  of  the  lesion  {clinically  doubtful  tumors). 

The  diagnosis  of  a  malignant  tumor  is  based  upon  the  palpation  of  the  tumor 
and  the  surrounding  breast,  changes  in  the  skin  and  subcutaneous  fat,  and  the 
changes  in  the  nipple. 

When  the  nipple,  skin,  and  subcutaneous  fat  are  apparently  unchanged,  it  is 
very  difficult  to  recognize  a  malignant  tumor  by  palpation  only.  However,  as  one's 
experience  increases,  one  will  find  that  a  positive  diagnosis  of  a  carcinoma  can,  in 
some  instances,  be  made  with  certainty  from  the  palpation  of  the  tumor.  The  car- 
cinoma has  a  characteristic  hardness  and  irregularity  in  outline.  When  the  tumor 
is  buried  in  breast  tissue,  and  the  subcutaneous  fat  is  thick,  the  palpating  finger  does 
not  reach  the  neoplasm,  and  only  feels  it  through  fat  and  breast  tissue.  It  is  in  such 
cases  that  the  benign  and  malignant  mass  cannot  be  differentiated,  and  an  explora- 
tory incision  becomes  necessary.  When  the  malignant  tumor  has  reached  the  sur- 
face of  the  breast  it,  as  a  rule,  can  be  distinguished  by  the  experienced  hand  by 
palpation  alone.  Measurements  of  the  diameters  of  the  different  quadrants  of  the 
breast  are  an  aid  in  diagnosis  (Fig.  437).  A  shortening  of  the  diameter  of  the 
quadrant  in  which  the  tumor  is  situated  is  a  strong  evidence  of  carcinoma. 


Fig.  436. — Lactation  Hypertrophy. 
Microscopic  drawing  by  Horn. 


186 


DISEASES    OF   THE   FEMALE    BREAST. 


The  palpation  of  definite  infiltration  of  the  breast  about  a  more  or  less  circum- 
scribed tumor  may  be  looked  upon  as  positive  evidence  of  its  malignancy. 

Retraction  of  the  7iipple  (Fig.  512)  is  a  pathognomonic  sign  of  carcinoma.  This 
may  be  visible  on  inspection.  In  other  cases,  if  the  surgeon  pulls  the  nipple  forward, 
its  fixation  to  the  deeper  structures  of  the  affected  breast  as  compared  with  the  nipple 
of  the  opposite  breast  will  allow  a  positive  diagnosis.  Tliis  early  change  in  the 
nipple  is  a  very  important  sign,  to  be  carefully  investigated.  One  must  remember 
the  possibility  of  congenitally  depressed  nipples,  and  also  that  a  previous  lactation 
mastitis,  with  or  without  abscess,  may  have  caused  the  nipple  of  the  affected  breast 
to  become  retracted.  In  my  own  experience  there  never  was  any  difficulty  in 
excluding  these  possibilities. 

Certain  changes  in  the  skin  and  subcutaneous  fat  over  the  position  of  the  palpable 
tumor  are  as  positive  signs  of  carcinoma  as  retraction  of  the  nipple.     The  definite 


m^ht 


Left 


Fig.  437. — Diagram  for  Charting  Position  of  Tumors  of  the  Breast. 

iV,  Nipple  zone;  x,  central  zone;    2/,  peripheral  zone;   Z,  axillary  prolongation;   7,  upper  and  inner;   77,  lower  and 
inner;   777,  lower  and  outer;   IV ,  upper  and  outer  quadrants. 


changes  which  can  be  recognized  by  inspection  or  palpation  need  little  discussion. 
Dimpling,  adherent  skin  (Fig.  511),  ulceration,  and  fungus  formation  (Fig.  504) 
require  little  experience  to  interpret  as  pathognomonic  evidence  of  a  malignant 
tumor.  It  is  the  first  very  slight  changes,  brought  out  by  palpation  only,  that  require 
experience  to  interpret,  and,  if  understood,  will  allow  a  positive  diagnosis  of  car-' 
cinoma.  The  least  atrophy  of  the  subcutaneous  fat  over  a  moderately  small  tumor 
is  a  sign  of  cancer.  If  the  surgeon  picks  up  the  skin  over  the  area  of  the  tumor  and 
can  demonstrate  shortening  of  the  fibrous  trabeculse,  this  can  be  looked  upon  as  a  sign 
of  cancer.  This  shortening  of  the  trabeculse  can  be  demonstrated  in  some  cases, 
when  all  other  means  fail,  by  grasping  the  breast  with  two  hands  and  pushing  for- 
ward the  area  of  the  breast  containing  the  tumor.  If  the  lesion  is  benign,  the  skin 
between  the  hands  will  bulge;  if  it  is  malignant,  in  some  cases,  the  trabeculae  will 
produce  one  or  more  dimples  (Fig.  507),  a  positive  sign  of  cancer. 

If  the  breast  containing  the  tumor  is  drawn  closer  to  the  chest  wall  than  the  un- 


GENERAL    REMARKS    ON   THE    CLINICAL    PICTURE    AND    DIAGNOSIS  187 

affected  breast,  this  may  be  looked  upon  as  a  sign  of  cancer.  Up  to  the  present 
time  I  have  never  observed  a  case  in  which  the  diagnosis  rested  upon  this  sign  alone, 
as  other  evidence  of  carcinoma  has  always  been  present. 

In  my  experience  palpable  glands  in  the  axilla  are  of  no  aid  in  the  early  recog- 
nition of  a  breast  carcinoma.  When  these  glands  are  sufficiently  large  and  hard 
to  allow  a  diagnosis  of  metastatic  carcinoma,  there  will  be  no  difficulty  in  the  diag- 
nosis of  the  primary  tumor.  Palpable  glands  in  the  axilla  are  frequently  observed 
in  benign  tumors  and  inflammations. 

In  the  clinically  doubtful  tumor  there  is  present  but  one  sign — a  palpable  mass. 
There  are  absolutely  no  changes  to  be  demonstrated  in  the  nipple,  skin,  subcutane- 
ous fat,  or  surrounding  breast.  This  mass  may  feel  distinctly  encapsulated,  an 
almost  positive  sign  of  a  benign  tumor.  Nevertheless,  some  malignant,  solid,  and 
cystic  tumors  may  give  to  the  palpating  fingers  a  sense  of  encapsulation.  The  mass 
may  feel  circumscribed,  but  not  encapsulated.  This  suggests,  but  is  not  positive 
evidence  of,  carcinoma.  If  the  benign  encapsulated  tumor  is  buried  in  breast  tissue, 
one  will  feel  the  mass  as  a  circumscribed  area;  encapsulation  cannot  be  made  out. 
The  mass  may  be  diffuse.  This  suggests  carcinoma,  but  some  benign  lesions  are 
diffuse;  mastitis,  senile  parenchymatous  hypertrophy,  and  a  small  encapsulated 
benign  tumor  (solid  or  cystic),  if  buried  in  breast  tissue,  may  feel  like  a  diffuse 
area  of  induration. 

When  there  is  nothing  but  tumor  on  which  to  base  the  diagnosis,  one  may  be,  in 
a  certain  number  of  cases,  sufficiently  positive  of  its  malignant  nature  from  palpation 
alone  to  proceed  with  the  complete  operation  without  an  exploratory  incision.  In 
all  other  cases  one  explores  the  tumor.  In  quite  a  number  one  may  feel  quite  con- 
fident of  its  benign  nature.  However,  the  possibility  of  exposing  an  early  carcinoma 
whenever  a  tumor  of  the  breast  is  explored  must  always  be  borne  in  mind.  For 
this  reason  the  operation  should  be  performed  with  all  preparatiofis  for  the  complete 
operation  for  carcinoma. 

Pain,  discharge  of  blood  from  the  nipple,  and  fluctuation  have  not  been 
mentioned  prominently  among  the  differential  signs  in  the  diagnosis  between  a 
benign  and  malignant  neoplasm.  Pain  is  not  a  sign  of  cancer;  as  a  rule,  it  is  more 
often  the  symptom  of  onset  of  a  benign  than  a  malignant  tumor,  and  usually  a  late 
symptom  in  cancer.  Discharge  from,  the  nipple  is  observed  in  the  infantile  breast, 
during  lactation,  in  senile  parenchymatous  hypertrophy,  and  is  associated  with  cysts 
containing  an  intracystic  papilloma,  when  the  discharge  is  usually  hemorrhagic. 
The  presence  of  the  discharge,  however,  does  not  exclude  a  carcinoma  in  the  last 
two  lesions,  which  frequently  become  malignant.  Fluctuation  is  often  a  misleading 
svmptom;  it  is  observed  in  solid  tumors  and  cysts,  either  benign  or  malignant.  The 
absence  of  fluctuation  does  not  exclude  a  cyst;  there  is  none  when  the  cyst  is 
tense. 

Local  edema  of  the  skin  and  subcutaneous  fat  about  the  palpable  tumor  in  a 
few  cases  allowed  a  positive  diagnosis  of  cancer  when  there  were  no  changes  in  the 
skin  or  nipple  for  further  aid.     This  edema  is  observed  in  very  rapidly  growing 


188  DISEASES    OF   THE   FEMALE   BREAST. 

malignant  tumors  and,  from  the  standpoint  of  prognosis,  has  so  far  been  associated 
with  a  fatal  end  result. 

Skin  Metastasis. — On  a  few  occasions,  when  a  positive  diagnosis  could  not  be 
made  of  the  exact  nature  of  the  palpable  tumor,  the  presence  of  two  or  more  lentic- 
ular, shot-like  nodules  in  the  skin  of  the  breast  could  be  interpreted  as  positive  signs 
of  carcinoma.  As  a  rule,  skin  metastases  appear  after  the  tumor  has  assumed  a 
clear  picture  of  malignancy.  Up  to  the  present  time  there  has  not  been  recorded  a 
single  case  of  permanent  cure  when  skin  metastases  were  present. 

General  Metastasis. — With  the  exception  of  the  skin  metastases  just  noted  I 
have  never  observed  a  patient  with  evidence  of  general  metastasis  before  the  primary 
tumor  in  the  breast  had  assumed  the  picture  of  malignancy. 

Cachexia  and  Change  in  the  General  Health.— In  my  experience  the  general 
condition  of  the  patient  has  never  been  of  any  aid  in  the  differential  diagnosis  of 
single  tumors  of  the  breast.  On  three  occasions  multiple  tumors  in  both  breasts 
associated  with  cachexia  suggested  metastatic  sarcoma,  which  proved  to  be  correct. 

Multiple  Tumors. — Carcinoma  of  the  breast,  for  practical  purposes,  is  uni- 
centric  in  origin.  It  first  appears  as  a  single  mass.  On  a  few  occasions  carcinomata 
have  appeared  simultaneously  in  both  breasts.  Now  and  then  patients  have  given 
the  history  of  feeling  first  one  lump,  then  another,  which  later  coalesced.  In  the 
few  cases  of  malignant  tumors  of  the  breast  in  which  I  could  palpate  more  than  one 
nodule,  one  has  always  been  clinically  malignant. 

Multiple  tumors  in  one  or  both  breasts  which  clinically  have  assumed  none  of 
the  characteristic  signs  of  cancer  may  be  looked  upon  as  benign.  In  a  woman 
under  twenty-five  they  are  usually  intracanalicular  myxomata.  The  adenofibroma 
is  less  frequently  multiple.  I  have  observed  a  few  cases  both  in  younger  and 
older  women.  Multiple  tumors  in  one  or  both  breasts  in  women  over  thirty,  and 
especially  between  forty  and  fifty,  are,  with  rare  exceptions,  simple  cysts,  associated 
with  some  stage  of  senile  parenchymatous  hypertrophy.  Cystic  adenoma  may  be 
multiple;  it  is  a  rare  tumor,  and  those  tumors  which  I  have  seen  were  in  women 
over  thirty.  Senile  parenchymatous  hypertrophy  without  cyst  formation  now  and 
then  appears  as  multiple  nodular  masses  in  one  or  both  breasts.  The  caked 
breast,  in  the  early  stage  of  lactation,  or  mastitis,  in  the  later  stage,  may  be  multiple. 

Metastatic  sarcoma  may  present  the  clinical  picture  of  multiple  tumors  of  one 
or  both  breasts,  and,  in  the  early  stage,  offers  no  general  evidence  of  malignant 
disease.  If  the  primary  tumor  is  concealed,  for  example,  in  the  ovary,  a  differential 
diagnosis  may  be  impossible  until  one  of  the  tumors  is  exposed. 

Cysts  with  intracystic  papillomatous  growths  have  been  observed  as  multiple 
tumors.     None,  so  far,  has  come  under  my  observation. 

In  women,  under  twenty-five,  suft'ering  from  multiple  tumors  of  one  or  both 
breasts  operation  is  not  indicated  unless  one  or  more  of  the  tumors  is  giving  sufficient 
pain  or  exhibiting  enough  growth  to  justify  its  local  removal.  In  my  experience  this 
rarely  takes  place. 

On  the  other  hand,  multiple  tumors  in  women  over  twenty-five  should  be  ex- 


GENERAL   REMARKS    ON   THE    CLINICAL   PICTURE   AND   DIAGNOSIS.  189 

plored  in  order  that  a  positive  diagnosis  of  their  nature  be  made.  The  treatment 
of  these  various  multiple  tumors  will  be  discussed  later. 

Important  Facts  to  be  Ascertained  in  the  History  of  a  Breast  Tumor. — 
Practically  the  diagnosis  of  a  breast  tumor  must  be  made  upon  the  examination  of 
the  tumor,  breast,  skin,  and  nipple.  With  rare  exceptions  only  can  the  details  ob- 
tained from  the  patient  as  to  the  history  of  the  growth  be  utilized  for  diagnostic 
purposes. 

Age. — If  the  patient  is  under  twenty-five,  this  fact  alone  is  presumptive  evidence 
of  a  benign  lesion,  but  carcinoma  has  been  observed  in  women  under  twenty-five. 
If  the  patient  is  over  twenty-five,  the  tumor,  on  the  theory  of  probability,  will  in  the 
majority  of  cases  be  a  carcinoma;  but  practically  all  forms  of  benign  lesions  are 
possible  in  older  women. 

The  long  duration  of  the  tumor,  without  any  positive  evidence  of  malignancy, 
points  to  a  benign  lesion ;  nevertheless  there  are  too  many  exceptions  to  allow  this 
alone  to  exclude  a  malignant  tumor. 

An  area  of  induration  during  lactation,  in  the  great  majority  of  cases,  is  due  to 
pyogenic  mastitis.  Carcinoma,  however,  has  been  observed  in  the  lactating  breast, 
and  in  its  early  stage  cannot  be  differentiated  from  mastitis. 

Position  of  Tumors  of  the  Breast. — Fig.  437  illustrates  how  the  breast  may  be 
divided  into  four  quadrants,  and  how  each  quadrant  may  be  subdivided  into  the 
nipple,,  middle  and  outer  zone,  and  axillary  prolongation.  I  am  unable  to  find 
that  the  position  of  the  tumor  is  of  any  aid  in  difl^erential  diagnosis.  Benign  tumors, 
except  the  papillomatous  cysts,  are  rarely  observed  in  the  nipple  zone.  Mastitis, 
unless  tubercular,  occurs  chiefly  in  the  outer  zone.  Scirrhus  carcinoma  is  quite 
frequent  in  the  nipple  zone.  All  tumors,  except  cancer  cysts,  occur  most  frequently 
in  the  upper  and  outer  quadrant.  In  carcinoma,  next  to  this  quadrant,  the  nipple 
zone  is  the  most  frequent  position.  Benign  and  malignant  tumors  may  be  situated 
in  any  portion  of  the  breast.  Cancer  has  been  observed  in  the  axillary  prolongation 
in  about  10  per  cent,  of  the  cases;  benign  tumors,  with  equal  frequency.  Between 
the  right  and  left  breast  there  is  not  enough  difference  to  be  at  all  suggestive.  In 
my  own  figures  the  number  of  tumors  in  the  left  breast  is  slightly  in  excess.  Cancer 
in  both  breasts  has  been  observed  in  about  5  per  cent. 

Palpable  tumors  have  been  present  in  the  breast  from  ten  to  twenty  years,  re- 
maining quiescent,  and  then  taking  on  rapid  growth.  In  some  the  tumor  proves 
to  be  malignant,  in  others  a  benign  cyst.  Of  great  interest  are  all  the  facts  in  regard 
to  the  onset  of  the  tumor,  its  duration,  etc.,  but  my  experience  teaches  me  that  it  is 
dangerous  to  place  chief  reliance  on  these  facts  in  the  differential  diagnosis.  This 
evidence  should  be  obtained  with  great  care,  and  used,  as  far  as  possible,  in  the 
differential  diajjnosis  of  the  clinicallv  doubtful  tumors.  If  the  tumor  on  examination 
has  the  signs  of  cancer,  evidence  from  the  clinical  history  must  be  given  no  weight. 

If  the  rule  is  followed  to  explore  at  once  every  single  tumor  in  ichich  a  clinical 
diagnosis  of  carcinoma  cannot  he  made,  the  diagnosis  must  in  the  end  rest  upon  the 
appearance  of  the  fresh  tissue  or  the  frozen  section. 


190  DISEASES    OF   THE    FEMALE    BREAST. 

The  facts  of  importance  to  be  obtained  from  the  history  may  be  summar- 
ized as  follows:  The  history  of  malignant  tumors  in  the  family;  the  possibility 
of  tuberculosis  in  the  family  or  evidence  of  tuberculosis  elsewhere  in  the  patient. 
A  very  small  proportion  of  patients  give  a  family  history  of  malignant  tumors. 
The  great  majority  of  cases  of  tuberculosis  of  the  breast  give  negative  family 
histories  and  have  no  e^ddence  of  tuberculosis  elsewhere.  The  possibility  of  a 
syphilitic  infection  should  be  borne  in  mind,  especially  as  to  primary  lesions  of 
the  nipple.     Gumma  and  luetic  mastitis  are  very  unusual  occurrences  in  the  breast. 

The  age  of  onset  is  perhaps  the  most  important  fact.  The  only  lesion  of  the 
infantile  breast  is  ectasia  of  the  ducts  with  a  discharge  from  the  nipple.  This  may 
be  associated  with  pyogenic  mastitis.  From  infancy  to  the  period  of  puberty  hyper- 
trophy the  breast  is  practically  immune  from  disease.  At  and  after  puberty  the 
fibro-epithelial  tumors  appear  (the  intracanalicular  myxoma  and  the  adenofibroma). 
These  tumors,  although  apparently  originating  during  puberty  hypertrophy,  may  not 
exhibit  growth  until  later.  This  explains  their  apparent  onset  in  w^omen  between 
twenty-five  and  forty-two.  During  the  menopause,  which  in  the  majority  of  women 
takes  place  between  forty  and  fifty,  senile  parenchymatous  hypertrophy  and  simple 
cysts  are  very  frequent.  After  the  menopause  the  possible  tumors  are  carcinoma, 
sarcoma,  and  simple  cysts,  with  the  probability  greatly  in  favor  of  carcinoma. 

Carcinoma  is  distinctly  a  disease  of  the  senile  breast,  but  it  may  occur  before 
senile  changes  take  place,  and  even  during  lactation  hypertrophy.  It  is  possible 
up  to  the  end  of  life.  In  women  under  thirty  carcinoma  is  very  rare.  The  pre- 
ponderance of  cases  is  observed  in  women  over  forty. 

The  Duration  of  the  Tumor. — In  a  table  of  forty-nine  cases  in  which  the  malig- 
nant tumor  had  assumed  no  positive  evidence  of  its  malignancy,  I  find  that  the  dura- 
tion of  the  tumor,  with  rare  exceptions,  has  been  one  year  or  less.  A  tumor  which 
has  been  present  one  year  or  more  and  still  manifests  no  positive  evidence  of  malig- 
nancy will,  in  the  majority  of  cases,  probably  turn  out  to  be  benign.  However,  we 
have  observed  a  small  infiltrating  scirrhus  of  five  years'  duration  and  an  adeno- 
carcinoma of  two  years'  duration,  still  clinically  doubtful,  and  since  at  the  pres- 
ent time  women  should  consult  surgeons,  as  in  the  majority  of  cases  they  do,  before 
the  end  of  the  year,  the  duration  of  the  tumor  becomes  of  less  and  less  importance. 

Trauma  has  not  been  an  important  etiologic  factor  in  the  history  of  either  benign 
or  malignant  tumors  of  the  breast. 

Lactation  Hypertrofhy^. — During  pregnancy  an  induration  of  the  breast  should 
be  explored  at  once ;  with  rare  exceptions  it  will  prove  to  be  either  tuberculosis  or 
carcinoma.  During  the  first  four  months  after  lactation  pyogenic  mastitis  is  the 
common  lesion.  After  the  fourth  month  a  mass  in  the  breast  should  be  regarded 
as  very  suspicious  of  carcinoma. 

Lactation  mastitis,  with  or  without  abscess  formation,  usually  leaves  no  palpable 
residual  scar  tissue,  and  apparently  plays  no  part  as  an  etiologic  factor  in  the  develop- 
ment of  a  later  carcinoma.  However,  if  a  palpable  mass  remains  after  a  lactation 
mastitis,  with  or  without  abscess,  such  a  mass  should  be  regarded  as  suspicious.     In 


GENERAL    REMARKS    OX   THE    CLINICAL    PICTLRE   AND    DIAGNOSIS.  191 

my  experience  carcinoma  may  eventually  develop,  sometimes  not  until  after  a  free 
interval  of  thirty  years. 

The  symptoms  of  onset  in  tumors  of  the  breast  are:  tumor,  pain,  retraction 
of  nipple,  dimpling  of  the  skin,  discharge  from  the  nipple,  and  palpable  axillary 
glands.  In  the  majority  of  cases  tumor  is  the  symptom  of  onset.  In  a  few,  pain 
may  precede  the  appearance  of  the  tumor  by  days,  weeks,  or  months.  Persistent 
localized  pain  in  the  breast  should  make  one  suspicious  of  a  tumor  formation.  I 
have  never  explored  the  breast  for  pain  only.  Pain  is  not  a  sjTnptom  of  malignant 
tumor.  It  is  more  common  in  benign  lesions,  and  may  be  an  early  symptom,  or  the 
symptom  of  onset,,  especially  in  cysts,  senile  parenchymatous  hypertrophy,  and  fibro- 
adenoma. It  is  a  late  symptom  in  cancer.  Retraction  of  the  nipple  may  be  looked 
upon  as  pathognomonic  of  cancer.  It  is  rarely  the  first  s\Tnptom.  I  have  observed 
it  but  once  without  a  palpable  tumor,  and  in  this  case  the  exploratory  incision  re- 
vealed a  small  infiltrating  scirrhus.  Dimpling  of  the  skin  in  a  few  instances  has 
been  the  first  sign  observed  by  the  patient.  In  all  of  my  observations  a  tumor  could 
be  felt.  A  discharge  from  the  nipple,  except  during  lactation  or  pregnancy,  may 
be  looked  upon  as  a  sign  of  a  benign  lesion  and  not  a  symptom  of  cancer.  If  the 
discharge  is  blood  or  a  cloudy  serum,  this  is  a  positive  sign  of  a  cyst  with  an 
intracystic  papillomatous  growth.  In  these  cases  such  a  discharge  is  frequently  ob- 
served by  the  patient  for  months  or  years.  In  senile  parenchymatous  hypertrophy 
one  can  sometimes  express  from  the  nipple  a  thick,  brownish  material — the  ac- 
cumulation of  degenerated,  desquamated  epithelium  in  the  dilated  ducts.  The 
patient  seldom  observes  this.  In  a  few  cases  the  patients  observed  palpable  glands 
in  the  axilla  before  they  felt  the  tumor.  I  have  never  observed  large  palpable 
glands  in  the  axilla  without  finding  the  tumor  in  the  breast.  I  do  not  look  upon 
palpable  glands  as  an  aid  in  the  differential  diagnosis  of  tumor  of  the  breast.  If 
the  glands  are  large  or  hard  enough  to  be  of  themselves  diagnostic  of  cancer,  the 
tumor  is  also  clearly  malignant,  clinically.  Palpable  glands  of  a  non-malignant 
nature  are  so  frequent  in  the  axilla  that  their  presence  or  absence  cannot  be  utilized 
as  evidence  for  or  against  the  malignant  nature  of  the  palpable  tumor  in  the  breast. 

Eczema  of  the  nipple  as  a  symptom  of  onset  I  will  discuss  later  under  Paget's 
disease. 

Marked  uniform  enlargement  of  both  breasts  in  a  young  woman  is  a  positive 
evidence  of  the  virginal,  diffuse  hypertrophy.  If  observed  during  gravidity,  it  is  the 
same  disease. 

Symmetric  enlargement  of  one  breast  in  the  female  is  due  to  tumor  formation, 
usually  benign,  and  most  likely  to  be  intracanalicular  myxoma.  In  some  instances 
it  has  been  due  to  adenofibroma. 

Unilateral  atrophy  of  the  breast  in  older  women  in  my  experience  has  always 
been  associated  with  a  palpable,  scirrhus  tumor  (atrophic  scirrhus).  In  younger 
women  unilateral  atrophy  may  follow  lactation  mastitis. 


192  DISEASES    OF   THE   FEMALE   BREAST. 

CLASSIFICATION  OF  LESIONS  OF  THE  FEMALE  BREAST. 
The  following  classification  is  based  upon  a  clinical  and  pathologic  study  of  1048 
lesions  of  the  breast  of  which  I  have  records  in  the  surgical  pathologic  laboratory. 
Of  these,  597  were  carcinoma,  18  sarcoma,  and  333  benign  lesions.  The  relative 
proportion  of  cases  observed  in  Halsted's  clinic  of  the  Johns  Hopkins  Hospital  is  as 
follows : 

Carcinoma 464  cases   =   67    % 

Sarcoma 14  cases   =      1-5% 

Benign  lesions 216  cases   =   31.5% 

I.  Anomalies. 
II.  Symptomatic  lesions. 

(A)  Pain  (neuralgia  of  breast,  mastodynia). 

(B)  Areas  of  congestion  (phantom  tumors). 

III.  Hypertrophies. 

(A)  Infantile  (duct  ectasia). 

(B)  Puberty  hypertrophy  (normal). 

(C)  Lactation  hypertrophy  (physiologic). 

(D)  Diffuse  bilateral  hypertrophy  (pathologic). 

(E)  Senile  parenchymatous  hypertrophy,  with  and  without  cyst  formation. 

IV.  Inflammations  (mastitides). 

(A)  Pyogenic,  with  abscess  formation. 

1.  Associated  with  lactation. 

2.  Not  associated  with  lactation. 

(B)  Chronic  interstitial,  with  parenchymatous  atrophy  and  without  cyst  or 

abscess  formation. 

(C)  Tuberculosis. 

(D)  Syphilis. 

V.  Benign  Tumors. 

(A)  Non-indigenous :  lipoma,  enchondroma,  lymphangioma,  dermoid  cysts, 

calcium  deposits,  encysted  foreign  bodies. 

(B)  FibroepitheKal  tumors: 

1.  Intracanalicular  myxoma  (periductal  myxoma,  or  fibroma — Warren). 

2.  Adenofibroma. 

(C)  Epithelial  tumors. 

1.  Adenoma  (cy-stadenoma). 

2.  Cysts  with  intracystic  papilloma. 

3.  Simple  cyst,  single  or  multiple  (see  senile  parenchymatous  hyper- 

trophy). 

4.  Galactocele  (see  lactation  hypertrophy). 
VI.  Malignant  Tumors. 

(A)  Carcinoma. 

1.  Adenocarcinoma. 


MASTITIS. 


209 


suspicious,  and  explored.  It  will  usually  be  found  to  be  carcinoma.  Chronic 
mastitis  is  possible,  but  very  rare.  A  chronic  non-tubercular  abscess  is  possible,  but 
unique;  it  may  he  confused  with  the  early  stage  of  a  gumma  or  tuberculosis. 

Lactation  Mastitis. — The  gross  and  microscopic  pathology  of  lactation  hyper- 
.  trophy  has  been  given  (Figs.  435  and  436) .  The  vessels  and  lymphatics  of  the  breast 
are  present  in  the  intralobular  stroma  about  the  ducts  and  acini.  The  portal  of  en- 
trance for  the  infection  is  usually  from  the  nipple;  it  is  possible  from  the  blood,  axilla, 
chest,  and  neighboring  skin,  due  to  the  ramification  and  anastomoses  of  the  lym- 
phatics of  the  breast. 

Indurations  of  the  breast  due  to  mastitis  are  practically  never  observed  in  the 
pregnant  period.     The  so-called  caked  breast  observed  during  the  first  few  days  after 


TTS.-.*- 


FiG.  460. — Sinus  Formation  in  Chronic  Pyogenic  Mastitis. 
Photograph  of  excised  breast;   sinuses  about  nipple  (Schapiro). 

labor  quickly  disappears.  So  rarely  does  the  early  caking  lead  to  abscess  formation 
that  we  may  look  upon  it  in  the  majority  of  instances  as  due  to  the  accumulation  of 
milk  secretion  and  to  congestion  of  the  vascular  breast  tissue. 

Pyogenic  mastitis  is  usually  acute,  and  is  observed  chiefly  before  the  fourth 
month  of  lactation.  The  area  of  induration  may  be  single  or  multiple,  in  one  or 
both  breasts.  It  is  frequently  associated  with  some  break  in  the  epidermis  of  the 
nipple.     The  general  symptoms  are  fever  and  leukocytosis. 

Fever  in  the  first  days  after  labor  is  usually  due  to  an  infection  through  the 
uterus ;  later  the  breast  must  be  examined  for  the  source  of  the  infection.  The  area  of 
induration  of  lactation  mastitis  is  tender,  and  over  it  there  may  be  slight  redness  of  the 
skin.     Resolution  is  possible  without  pus  formation  at  this  stage.     The  clinical 

VOL.  II — 14 


210 


DISEASES    OF   THE    FEMALE   BREAST, 


signs  of  abscess  are  redness  and  edema  of  the  skin,  fixation  of  the  skin  to  the  in- 
durated mass,  bogginess  or  fluctuation  of  the  mass. 

If  the  abscess  is  not  properly  incised,  it  may  rupture  spontaneously  through  the 
skin  and  heal.  Spontaneous  cures  of  abscess  are  rare.  The  abscesses  may  be 
multiple  in  one  breast,  rupture,  leaving  a  breast  with  numerous  sinuses,  indurated, 
and  with  a  retracted  nipple  (Fig.  460).     Healing  of  the  sinuses  may  take  place. 

Lactation  mastitis  without  acute  symptoms  is  possible,  but  less  frequent  than  the 
acute.  There  may  be  simply  an  area  of  induration,  with  or  without  fever.  This 
area  may  be  slightly  tender,  and  should  disappear  after  a  time.  This  is  the  chronic 
form  without  abscess  formation.  On  the  other  hand,  the  area  may  gradually  in- 
crease in  size  until  it  involves  a  quadrant  or  a  hemisphere,  and  gives  rise  to  the  clinical 
picture  of  a  tumor  (Fig.  461) — a  chronic  mastitis  abscess. 

IMultiple  minute  abscesses  of  the  breast  due  to 
chronic  mastitis  during  lactation  have  been  observed. 

The  area  of  induration  of  a  lactation  mastitis,  with 
or  without  abscess,  may  persist  unchanged  for  months 
or  years.  In  my  experience  carcinoma  usually  develops 
in  such  an  area. 

Diagnosis  and  Treatment. — In  the  diagnosis  one  is 
anxious  to  recognize  the  lesion  the  moment  pus  forma- 
tion has  taken  place,  and  to  follow  this  by  an  incision  for 
drainage.  On  the  other  hand,  in  the  more  chronic  cases 
one  must  always  bear  in  mind  the  possibility  of  carci- 
noma. An  area  of  induration  in  the  lactating  breast  if 
due  to  pyogenic  mastitis  should  disappear,  or  exhibit 
symptoms  of  an  abscess  very  quickly.  The  latter  de- 
mands immediate  incision ;  the  former,  after  a  delay  of 
a  few  weeks,  exploration. 
In  exploring  an  induration  of  the  lactating  breast  the  following  lesions  are 
possible:  a  galactocele  (p.  196);  a  benign  tumor  (p.  212);  tubercular  mastitis  (p. 
211);  a  cancer  cyst  (p.  246);  a  solid  carcinoma  (p.  240),  or  a  pyogenic  mastitis. 
The  gross  appearance  of  the  fprmer  will  be  described,  and  should  be  differenti- 
ated from  mastitis. 

In  pyogenic  mastitis  the  knife  will  pass  through  lactating  breast  from  which 
milk  can  be  expressed ;  then  a  zone  of  condensed  breast  tissue  slightly  hemorrhagic, 
from  which  milk  cannot  be  expressed;  then  a  distinct  abscess  wall  lined  by  granu- 
lation tissue,  after  which  purulent  material  is  encountered. 

In  the  chronic  abscess  the  wall  is  thicker,  the  granulation  tissue  lining  more 
distinct,  and  the  pus  thinner. 

In  a  few  cases  there  is  not  a  single  abscess,  but  multiple  minute  abscesses.  I 
have  never  observed  the  latter  in  a  malignant  tumor  of  a  lactating  breast. 

Incision  and  drainage  are  sufficient  for  the  single  acute  abscess.  In  the  chronic 
abscess  the  wall  should  be  excised. 


Fig.  461. — Chronic  Pyogenic 
Lactation  Mastitis,  Abscess. 
Age,  twenty-four;  onset  of 
tumor,  two  months,  in  second 
month  of  lactation;  mistaken  for 
cancer  cyst.     Halsted's  clinic. 


MASTITIS. 


211 


/ 


In  the  chronic  condition  with  multiple  abscesses  or  sinuses  the  breast  will  have 
to  be  removed. 

In  the  acute  abscess,  before  incision,  passive  hyperemia  after  the  method  of 
Bier,  with  a  glass  jar,  should  be  tried  as  a  method  of  treatment.  Bier  claims  that 
resolution  more  frequently  follows  such  treatment.  When  the  incision  is  made,  it 
can  be  small,  and  to  the  opening  a  vacuum  cup  of  Bier  should  be  applied  two  or  three 
times  a  day.  There  is  no  space  to  discuss  Bier's  treatment  of  infections,  but  there 
is  no  doubt  in  my  mind  that  this  method  has  a  distinct  place  in  the  treatment  of 
pyogenic  infections  of  the  breast,  and  perhaps  tubercular. 

My  colleague,  Williams,  agrees  with  me  that  massage  is  contraindicated  dur- 
ing lactation.  It  is  of  no  value  for  caked  breast  or  mastitis,  and  would  be  very 
harmful  if  the  area  of  induration  were  due  to  carcinoma. 

The  usual  treatment  employed  to  check  the  secretion  of  milk  when,  for 
various  reasons,  the  infant  is  not  to  nurse  the 
breast,  is,  according  to  Williams,  entirely 
unnecessary.  The  secretion  of  milk  will 
cease  if  the  child  is  simply  removed.  The 
patient  may  need  one  or  two  small  doses 
of  morphin.  Pumping,  massage,  ointments, 
and  bandaging  simply  increase  discom- 
fort. 

Mastitis  of  the  Non-lactating  Breast. — 
The  clinical  picture,  diagnosis,  and  treatment 
do  not  differ  from  the  same  pyogenic  lesion  in 
the  lactating  breast.  This  form  of  mastitis  is 
rare.  It  may  be  due  to  a  pyogenic  osteomyel- 
itis of  a  rib  (Fig.  462),  traumatism,  or  it  may 
be  secondary  to  infections  in  the  axilla,  arm, 
chest,  or  neighboring  skin.  It  has  been  ob- 
served now  and  then  during  typhoid  fever 
and  in  other  infectious  diseases.  Resolution  may  take  place.  Abscess  is  the  usual 
result. 

An  area  of  induration  due  to  chronic  mastitis  in  a  non-lactating  breast  may  be 
considered  unique.  I  have  seen  two  cases:  one  due  to  an  encysted  sequestrum,  in 
which  the  osteomyelitis  of  the  rib  produced  no  clinical  symptoms;  the  other 
followed  a  subcutaneous  injection  of  normal  salt  solution. 

Senile  parenchymatous  hypertrophy  (p.  200)  has  been  called  chronic  cystic 
mastitis,  but  as  the  etiologic  factor  is  not  knovv-n,  I  have  preferred  to  discuss  it  among 
hypertrophies  rather  than  inflammations. 

Tubercular  Mastitis  (0  percent,  of  benign  lesions). — Tuberculosis  of  the  breast 
has  been  observed  to  begin  between  the  ages  of  twenty-five  and  thirty-five;  never 
before  puberty  hypertrophy,  and  a  little  more  frequently  in  the  non-lactating 
breast.  It  has  been  observed  during  the  early  months  of  lactation,  and  must  then 
be  distinguished  from  pyogenic  mastitis. 


Fig.   462. — Chronic  Mastitis  Abscess  from 

Osteomyelitis  of  Rib. 

Halsted's  clinic. 


212 


DISEASES    OF   THE   EEMALE    BREAST. 


It  occurs  more  frequently  after  the  fourth  month  of  lactation,  like  carcinoma. 
There  may  be  no  family  history  of  tuberculosis  and  no  evidence  of  tuberculosis  else- 
where in  the  patient.  As  a  rule,  but  one  breast  is  involved,  and  in  this  breast  but  one 
focus. 

The  symptom  of  onset  is  a  single  area  of  induration,  usually  in  the  nipple  zone, 
rarely  in  the  periphery  of  the  breast.  Signs  of  abscess  develop  quickly  without  acute 
symptoms,  and  spontaneous  rupture  with  sinus  formation  is  observed  in  the  majority 
of  cases  before  the  ninth  month. 

Not  until  the  abscess  or  sinus  has  formed  can  tuberculosis  be  diagnosed  clinically. 
At  the  exploratory  incision  the  granulation  tissue  lining  a  tubercular  abscess  (Fig. 
463)  has  a  sufficiently  characteristic  appearance  to  allow  a  positive  diagnosis.     In 

the  early  stage  before  abscess  for- 
mation one  undoubtedly  would  be 
able  to  make  out  caseation.  Tu- 
berculin may  be  used  for  diagnosis 
in  doubtful  cases. 

Up  to  the  present  time  complete 
excision  of  the  breast  has  been  the 
routine  treatment  in  tuberculosis. 
However,  if  the  focus  is  seen  early 
I  am  of  the  opinion  that  local  ex- 
cision with  the  preservation  of  the 
breast  should  be  done  if  possible. 

Syphilitic  Mastitis  and 
Gumma. — Excluding  primary 
lesions  of  the  nipple  and  areola 
and  secondary  manifestations  in 
the  skin  over  the  breast,  true 
syphilis  of  the  breast  tissue  must 
be  rare.  I  have  no  observations, 
nor  had  Billroth  or  Gross.  Bill- 
roth was  skeptical  of  many  of  the 
cases  recorded  in  the  literature.  Williams  describes  a  diffuse,  syphilitic  mastitis 
and  a  circumscribed  gumma,  both  in  acquired  and  hereditary  syphilis.  Sheild 
adds  a  few  cases.  These  two  authorities  state  that  the  patients  had  other  mani- 
festations of  lues,  with  few  exceptions. 

In  view  of  the  rarity  of  syphilitic  mastitis  I  do  not  believe  such  a  diagnosis  should 
be  made,  even  with  manifestations  of  syphilis  elsewhere,  until  the  lesion  has  been 
explored. 


Fig.      463. — Circumscribed     Tubercular     Abscess     Sur- 
rounded BY  Fibrous  Breast. 

Colored  woman,  aged  thirty-five  ;  induration  three  months; 
spontaneous  rupture  with  sinus  formation  three  weeks. 
Halsted's  clinic. 


Beotgn  Tumors. 
The  non-indigenous  benign  connective-tissue  tumors  rarely  develop  in  the  breast 
tissue. 


BENIGN  TUMORS. 


213 


Lipoma  may  be  single  or  multiple.  The  large  tumors  may  reach  a  great  size 
(Fig.  464),  and  should  not  be  difficult  to  differentiate  from  the  large  intracanalicular 
myxoma.  A  smaller  lipoma  buried  in  the  breast  tissue  would  only  be  recognized  at 
the  exploratory  incision.  I  have  observed  but  three  cases:  two  were  multiple  small 
tumors,  one  a  large  tumor.  The  literature  has  recently  been  collected  by  Delage  and 
Massabiau.^ 

Fibroma.^I  have  never  observed  this  tumor  in  the  breast.  This  agrees  with 
the  observations  of  Billroth  and  Schimmelbusch.  Williams  claims  to  have  seen  pure 
fibroma.  In  the  older  adenofibroma  it  is  possible  for  the  parenchyma  to  undergo 
complete  atrophy. 

Areas  of  Calcification. — I  have  seen  calcification  in  an  adenofibroma  of  many 
years'  duration  in  the  breast  of  an  adult  woman.  Definite  crepitus  was  elicited  and 
the  diagnosis  made.  There  was  a  carcinoma  in  the  other  breast.  Billroth  observed 
calcified  areas  in  the  wall  of  simple  cysts,  in  adenofibroma  and  scirrhous  carcinoma. 
Williams  records  calcification  in  a  sarcoma.  I  have  never  observed  calcification  in 
malignant  tumors.  Thayer^  records  a  case  of  dif- 
fuse calcification  in  the  breast  and  axillary  glands 
after  an  incision  of  a  post-typhoid  mastitis  abscess. 
Thayer  looks  upon  the  calcification  as  due  to  the 
reaction  between  the  calcium  in  the  subcutaneous 
infusion  given  into  this  breast  because  of  a  hemor- 
rhage, and  the  iodin  and  the  iodoform  gauze  used 
for  drainage. 

Enchondroma  and  Osteoma. — Billroth  found 
but  one  case  of  an  enchondroma,  which  also  con- 
tained some  bone  tissue.  Williams  and  Sheild 
record  a  few  cases.  I  have  never  observed  an  ex- 
ample of  these  tumors  and  find  nothing  in  recent 

literature.  Areas  of  cartilage  without  bone  formiation  have  been  observed  in  the 
breast  of  female  dogs.  I  have  observed  cartilage  in  the  so-called  mixed  tumor  of 
the  breast,  which  is  nothing  more  than  an  intracanalicular  myxoma  with  islands  of 
cartilage,  and  this  tumor  usually  has  become  a  sarcoma. 

Angioma. — Skin  and  subcutaneous  angioma  might  involve  the  breast.  Billroth 
was  of  the  opinion  that  all  angiomata  of  the  breast  were  of  this  origin.  Sheild  and 
Williams  record  a  few  cases  of  angioma  without  connection  with  the  skin  or  sub- 
cutaneous fat.  We  know  that  primary  angioma  of  muscle  is  possible;  it  has  lieen 
observed  in  the  parotid  gland  and  other  organs;  why  not  in  the  breast?  I  have 
observed  one  fibro-angioma  which  clinically  was  compressible,  very  vascular  on 
section,  and  under  the  microscope  contained  so  much  vascular  tissue  in  the  stroma 
between  the  parenchyma  that  I  looked  upon  the  tumor  as  an  example  of  a  mixed 
angiofibroadenoma. 

'Delage  and  Massabiau:    R^vue  de  Chir.,  xxv,  No.  10. 
^Thayer:    Johns  Hopkins  Hosp.  Bull.,  Feb.,  1906. 


Fig.  464. — Huge    Lipoma  of    Breast 
(from  Billroth). 


214  DISEASES    OF   THE   FEMALE    BREAST. 

The  recognition  and  treatment  of  angioma  of  the  breast  should  not  be  difficult. 
It  cannot  be  mistaken  for  the  angiosarcoma  and  the  hemorrhagic  carcinoma  which  I 
will  describe  later. 

Hydatid  Cysts. — LeConte^  reports  an  observation  of  his  own  and  gives  the 
literature. 

The  diagnosis  must  rest  upon  the  demonstration  of  the  booklets.  Clinically,  the 
picture  is  that  of  a  chronic  pyogenic  abscess,  of  a  doubtful  tumor.  The  cyst  usually 
contains  purulent  material. 

Encysted  Foreign  Bodies. — The  example  of  an  encysted  sequestrum  from  a 
rib  has  been  recorded  (p.  211).  Chnically,  it  presented  itself  as  a  small  area  of  in- 
duration. The  diagnosis  was  not  made  until  the  exploratory  incision.  In  one  case 
of  carcinoma  of  the  breast  I  found  the  parasite  of  trichinosis  encysted  in  the  breast 
and  pectoral  muscle. 

Dermoid  Cysts.^ — These  tumors  are  rare;  they  may  be  in  the  skin  or  buried  in 
the  breast  tissue.  The  benign  cyst  never  assumes  the  clinical  picture  of  a  malignant 
tumor.  If  infected,  it  may  resemble  an  abscess.  The  dermoid  is  recognized  at  the 
exploratory  incision  by  its  distinct  cyst  wall,  easily  separable  from  the  surrounding 
tissues,  and  by  its  characteristic  contents. 

The  dermoid  may  become  malignant.  Usually  this  change  is  associated  with 
involvement  of  the  skin  which  allows  a  clinical  diagnosis  (this  was  so  in  my  one 
observation).  If  not,  the  wall  of  the  malignant  dermoid  cyst  is  thick,  fixed  to 
the  surrounding  tissue,  and  on  section  has  the  typical  appearance  of  cancer. 

'     FIBRO-EPITHELIAL  TUMORS. 

Among  333  benign  tumors  of  the  breast  39  per  cent,  were  of  the  fibro-epithelial 
type:  27  per  cent,  intracanalicular  myxomata,  and  12  per  cent,  adenofibromata. 

Intracanalicular  Myxoma. — This  most  common  tumor  of  the  young  female 
breast  is  due  to  a  hypertrophy  of  the  periductal  or  intralobular  stroma  which  develops 
during  puberty  hypertrophy. 

Clinically,  the  tumor  may  be  single  or  multiple,  in  one  or  both  breasts,  of  small 
size,  or  it  may  appear  as  a  large  tumor,  involving  part,  half  of,  or  the  entire  breast. 

Multiple  Tumors. — In  about  20  per  cent,  of  cases  the  tumors  have  been  multiple, 
in  one  or  both  breasts.  In  the  majority  the  age  of  onset  has  been  less  than  twenty- 
five  years;  in  a  few  the  multiple  tumors  had  not  been  observed  by  the  patient  until 
after  twenty-five,  up  to  forty  years.  The  clinical  picture  and  the  fresh  appearance  of 
one  of  the  multiple  tumors  does  not  differ  from  that  of  the  single  tumor. 

When  the  patient  is  under  thirty  the  clinical  diagnosis  is  not  difficult,  and,  in  my 
experience,  operation  is  not  indicated  unless  one  of  the  tumors  is  the  seat  of  pain  or 
growth.     The  tumor  should  be  removed. 

So  far,  in  my  observation,  it  has  never  been  necessary  to  sacrifice  the  breast.  I 
have  observed  some  of  these  cases  fifteen  years.  The  small  multiple  tumors  have 
given  no  further  trouble.  In  some  the  breasts  have  lactated,  and  the  tumors  have 
'LeConte:    Amer.  Jour,  of  Med.  Sciences,  Sept.,  1901,  cxii,  277. 


BENIGN   TUMORS. 


215 


not  given  any  discomfort.     I  have  noted  before  that  if  such  a  tumor  is  removed 
during  lactation  its  parenchyma  shows  the 
characteristic  hypertrophy  of  the  physiologic 
process  present  in  the  breast  tissue. 

^Mien  the  patient  is  over  thirty,  it  would 
be  difficult  to  differentiate  multiple  intra- 
canalicular  myxomata  from  multiple  cysts. 
In  both  cases,  however,  whether  the  tumors 
are  giving  pain  or  exhibiting  growth  or  not, 
at  least  one  should  be  explored  and  removed 
for  diagnosis. 

Up  to  the  present  time  I  have  never  ob-  _ 
served  either  a  carcinoma  or  a  sarcoma  in  a 
breast  which  was  the  seat  of  multiple  intra- 
canalicular  myxoma.  For  this  reason,  in 
the  relatively  very  few  cases  in  which  the  multiple  intracanalicular  myxoma  is 
observed  in  the  breast  of  women  over  twenty-five  complete  removal  of  the  breast  is 
not  necessary  to  insure  the  patient  against  cancer  or  sarcoma. 


Fig.  465. — Small  Encapsulated  Intracanaiic- 

ULAR  Myoma. 

Photograph  of  fresh  specimen  by  Schapiro. 


Fig.    466. — Medium-sized    Intrac.4_n-alicular    Myxoma,  with    Characteristic  Small  and  Large   Lobula- 
tions. 
Female,  aged  thirty,  tumor  two  years.     Photograph  from  painting  of  specimen. 


216  DISEASES    OF   THE    FEMALE    BREAST. 

Small  Single  Tumors. — In  at  least  70  per  cent,  the  intracanalicular  myxoma 
has  appeared  as  a  small  single  tumor.  The  age  of  onset  has  varied  between  fifteen 
and  twenty-five  years.  Between  twenty-five  and  forty-three  I  have  observed  a  few 
scattered  cases.  The  tumor  is  freely  movable,  and,  when  it  can  be  palpated,  dis- 
tinctly encapsulated;  the  majority  have  a  characteristic  lobulation  and  elasticity. 
In  a  few  instances  the  tumors  have  been  smooth  and  tense,  resembling  an  adeno- 
fibroma  or  a  cyst.  Growth,  as  a  rule,  is  slow.  The  duration  of  the  tumor  has  varied 
from  a  few  weeks  to  ten  years. 

Pathology. — At  the  exploratory  incision  the  tumor  has  a  distinct  capsule  (Plate 

II,  Fig.  1;    and  Fig.  465)  and  is  usually  lobulated  (Fig.  466).     The  cut  surface 

exhibits  roundish,  bulging,  myxomatous   lobules  of  from  1  to 

rt,  '■.       ,  /".  •    A^  3  mm.  in  diameter.     The  microscopic  appearance 

■     .i^' J^\     V^'i„-  (Fig-  467)  is  sufficiently  characteristic  to  recognize 

,  h    ■    "?    X  'S'--         o--   ^       easily  in  the  frozen  section. 

'y^p  In  the  vounger  tumor  one  will  observe,  micro- 


,.L- 


^     X  ;        ^       '■/ ^' "  j.''  ^^  scopically,  more  parenchyma;  the  epithelial  cells 

?■'   "'     ^^  /  "'.,     J,*—'        "'''"-       will  be  of  a  higher  type,  and  exhibit  proliferation, 
"      "\      ■    i^       "~,.         /7      J--  deo'eneration,  desquamation.     Given  a 

i  J.   U '  /        -  J  -.  '     °    ■  -'  verv  small  voung  tumor  in  the  female 

-----  ;-:-^'  ^5  ?,^'     :■/"  \^  breast,  it  will  be  difficult  to  differen- 

^'^^0,    '■'''■'" J^  'v  ^'    '   ^         '  ^^^^^  macroscopically  and   microscop- 

^  "'"T.     ■      •'■/^^»  '  '-  '       \   '    '  icallv  the  cvstic  adenoma,  the  adeno- 

^,^-,      -        "'    ''  ■=-  fibroma,     and      the      intracanalicular 

.   %    ~-:.       :■  '^  :  mvxoma.     A  difi^erential   diagnosis  is, 

-  %^  ^^^        ^ ;  of  course,  oi  no  practical  importance. 

As  the  tumors  grow  larger  and  become 
older   the  distinctly  gross  and  micro- 
scopic features  of  the  type  become  evi- 
dent. 
^    ^:^  Treatment. — I  am  of  the  opinion 

^       ^,     ^  ^,  that  these  single  tumors  should  be  re- 

FiG.  467. — Intracanalicular  Myxoma.  o 

Low-power  microscopic  drawing  by  Horn.  mOVcd.         lu     the     yOUUgCr    WOmCU     re- 

moval of  such  a  tumor  insures  the 
patient  against  the  complete  removal  of  the  breast  should  this  tumor  be  allowed  to 
grow  to  great  size;  and  against  the  possibility  of  sarcoma,  which  usually  takes  place 
when  the  intracanalicular  myxoma  has  reached  a  large  size.  In  the  older  woman 
the  operation  is  imperative,  because  a  positive  clinical  diagnosis  cannot  be  made. 
Excision  of  the  tumor,  if  it  is  encapsulated  and  has  the  characteristic  appearance 
of  a  benign  neoplasm,  is  sufficient;  but  if  the  tumor  looks  very  cellular,  it  should 
be  treated  as  a  sarcoma  (seep.  249). 

Up  to  the  present  time,  in  about  ten  single,  small^  intracanalicular  myxomata  ob- 
served in  the  breast  of  women  between  thirty  and  forty-three  one  has  been  a  sar- 
coma, cured  by  the  complete  operation. 


BENIGN   TUMORS.  217 

The  Single  Large  Tumor. — In  about  10  per  cent,  of  cases  the  intracanalicular 
myxoma  has  involved  half  or  the  entire  breast  (Fig.  468).  With  few  exceptions 
the  age  of  onset  has  been  over  thirty;  the  oldest,  fifty-two.  The  duration  of  the 
tumor  varied  from  one  to  four  years. 

To  illustrate  my  point  that  a  single  small  tumor  in  the  breast  of  a  young  woman 
should  always  be  removed,  I  cjuote  the  following  example:  A  woman  of  twenty 
observed  a  small  tumor  in  the  right  breast;  it  required  ten  years  for  this  tumor  to 
involve  the  entire  breast.     An  early  operation  would  have  prevented  mutilation. 

As  the  intracanalicular  myxoma  grows  larger  its  clinical  diagnosis  is  easier,  the 
lobulation  and  elasticity  become  more  distinct,  and,  in  spite  of  the  size,  the  skin  and 
nipple  remain  normal.  In  my  experience  there  should  be  no  difficulty  in  differen- 
tiating the  large  intracanalicular  myxoma  from  the  medullary  carcinoma.  The 
latter  would  never  reach  such  a  size  with- 
out involvement  of  the  skin. 

Treatment. — In   view   of    the   ten-    , 
dency  of  the  large  tumor  to  become  a 
sarcoma  one  should  pay  no  attention  to 
its  pathology,  but   be  governed  by  the 

clinical  picture.     Remove  the  breast,  an  i 

area  of  skin,   and   the   major  pectoral  | 

muscle  (see  p.  274).  / 

Pathology. — As  the  intracanalicular 
myxoma  becomes  larger  and  older  one 
of  two  definite  changes  may  take  place: 
one  entirely  benign,  the  other  malignant. 
The  benign  change  manifests  itself  by 
the  great  increase  of  the  fibrous  trabecule      ^'«-  468.-Large  intracanalicular  myxoma,  right 

c  Breast,  Simulating  Unilateral  Hypertrophy. 

marking  the  lobules,  by  myxomatous  de- 
generation up  to  the  development  of  cysts,  and  by  the  atrophy  of  the  epithelial 
parts  of  the  tumors.     The  malignant  changes  take  place  in  the  myxomatous  tissue; 
the  gross  lobulation  is  lost,  the  tissue  becomes  firmer  and  more  cellular. 

The  largest  tumors  of  the  breast  belong  to  the  intracanalicular-myxomatous  type. 
The  huge  tumors  found  illustrated  in  the  older  monographs  l)y  Velpeau,  Brodie, 
Billroth,  and  Gross  are  of  this  character,  and  were  called  serocystic  sarcomata. 

Recurrent  Intracanalicular  Myxoma. — In  a  few  instances,  when  a  single 
tumor  has  been  removed,  later  one  or  more  tumors  of  the  same  character  may  de- 
velop in  the  remaining  breast  tissue.  I  should  look  upon  such  an  observation  as  an 
example  of  multiple  tumors  developing  at  different  periods,  rather  than  a  recurrence. 
Theoretically,  this  should  happen  frequently;  practically,  I  have  seen  it  on  but  two 
occasions. 

Spontaneoiis  Disappearance  of  Intracanalicular  Myxoma. — In  view  of  the  com- 
parative frequency  of  this  tumor  in  the  breast  of  young  women  and  its  rarity  in  older 
women,  and,  so  far  as  my  observations  go,  its  absence  in  the  breast  which  is  the  seat 


218 


DISEASES    OF    THE    FEMALE    BREAST. 


of  carcinoma,  we  may  be  justified  in  concluding  that  a  small  intracanalicular  myxoma 

may  disappear. 

I  have  never  observed  a  carcinoma  to  develop  in  an  intracanalicular  myxoma. 

Adenofibroma. — Clinically,  like  the 
intracanahcular  myxoma,  we  observe  the 
adenofibroma  as  a  single  or  multiple  small 
tumor,  or  as  a  single  larger  tumor.  The 
age  of  onset  is  the  same,  and  in  infre- 
quency  this  tumor,  either  single  or  mul- 
tiple, in  women  over  twenty-five,  resembles 
the  intracanalicular  myxoma. 

The  single  small  tumor  is  rarely  lobu- 
lated,  may  be  spherical,  is  quite  hard  in 
consistency,  and  is  usually  associated  vrith 
pain  and  tenderness.  It  may  be  of  rapid 
growth.  In  quite  a  few  cases  the  tumors 
have  remained  quiescent  for  years.  The 
older  the  tumor,  the  more  fibrous.  Some 
may  become  calcified.  I  am  quite  con- 
fident that  in  a  few  cases  of  carcinoma 
with  a  history  of  a  quiescent,  small  tumor 

of  from  ten  to  thirty  years'  duration,  first  observ^ed  w^hen  the  patients  were  under 

thirtv,  the  original  tumor  was  an  adenofibroma  or  a  cvstic  adenoma. 


Fig 


Breast 


469. fibroadexoma,     accessory 

Tissue. 
Photograph  from  Halsted's  chnic  (by  Wright). 
The  ttimor  is  clasped  by  the  fingers  of  the  nurse; 
breast  to  the  medial  and  lower  side.  (Clinical  pic- 
ture like  unilateral  hjTjertrophy.)  Girl,  aged  nine- 
teen, tumor  nine  months. 


Fig.   470. — Fibroadenoma. 
Sketch  of  external  appearance  after  removal  from  center  of  breast.     Girl,  aged  si.xteen,  tumor  six  weeks.     Clin- 
ical picture  that  of  unilateral  hypertrophy. 


BENIGN   TUMORS.  .  219 

It  is   these  observations  which  emphasize  the  importance  of  removing  every 


Fig.  471. — Fibroadexom.\,  Accessory  Breast  Tissue. 
Gross  appearance  of  section  of  alcohol  specimen.     See  also  Plate  I,  Fig  1. 

single  tumor  of  the  breast,  irrespective  of  the  age  of  the  patient  or  the  duration  of  the 
tumor,     I   have   also   one   observa- 
tion   of   a    diffuse  carcinoma   in  a    W^-j^'^-.-^^^^    .-^ 
breast  the  seat  of  multiple  adeno-    'VVJ  "^  ,.  ..-,,;-.- 

fibroma  of  long  duration.  ^^^^?^;r-!  :}':K ":--: ■■■■■: :  '*-:-u> 

The  adenofibroma  never  reaches     ---V;"   ^."  /-"•'^•'^'  ■:'!''•'"  '^'-./y 
the  size  of  the  larger  intracanalicular     '{';;;   /.  '-.~  '  -^H'^  '■-    '■■-''-  '^^^:^^- 
mvxoma,  and,  so  far,  has  never  been       o^;^     '-^l  ■  ■ ;  :.  ^ .    ^     ^^A^^f^^ 
observed    in    older    women.       The    '4^ y^^%v:^  :/->;''    -'^^'% ; 
larger  tumors,  when  situated  in  the     '_-■  '-/■  .y^-:^:^  : ; -^.^  :~ 

center  of  the  breast   (Fig.  470)  or    .Q;-.,.-  A-^^^c^^;- 

outside   of    the    breast    (Fig.    469)        :.  ^  " 

(accessory  breast  tumors),  may  give 
the  picture  of  a  unilateral  hyper- 
trophy. If  such  tumors  are  care- 
fully studied  at  the  exploratory  in- 
cision, the  breast  may  be  preserved. 
In  three  of  the  cases  sent  to  my 
laboratory  the  entire  breast  had 
been  unnecessarily  removed. 

Pathology. — ^"\^len  the  smaller 
tumor  is  found  in  the  breast  of  an 
older  woman,  its  hardness  may 
suggest  a  carcinoma,  and  when 
explored,  it  may  resemble  a  carcinoma  to  the  inexperienced  eye.     A  rapid  frozen 


Fig.  472. — Fibroaden-oma. 

Microscopic    drawing,  L.  Neilson-Ford.     Fibrous   tissue   in 

excess;    parenchyma  undergoing  atrophy. 


220 


DISEASES   OF   THE   FEMALE   BREAST. 


section  of  an  adenofibroma  may  resemble  at  first  sight  a  carcinoma,  especially  if 
the  tumor  is  fibrous  and  the  parenchyma  undergoing  pressure  atrophy. 

This  tumor  always  has  a  distinct  capsule,  which  is  absent  in  carcinoma.  The 
appearance  of  the  freshly  cut  surface  in  the  older  fibrous  tumors  shows  splits  and 
crevices  without  epitheHal  debris  (Fig.  471).  In  the  younger  and  in  the  larger 
tumors  the  pink  elevated  dots  of  parenchyma  (Plate  I,  Fig.  1)  are  distinctive  features. 
Microscopically  the  older  tumor  (Fig.  472)  is  characterized  by  excessive  fibrous 
stroma,  and  the  parenchyma  with  the  epitheHal  cells  of  a  low  type  is  under- 
going pressure  atrophy.  In  the  younger  tumors  and  in  the  larger  tumors  of  accessory 
breast  tissue  the  parenchyma  predominates,  resembHng  the  picture  of  puberty  hyper- 
trophy, but  not  showing  the  normal  architecture  of  the  breast  lobule  (Fig.  473). 


Fig.  473. — Adenofibroma. 
Photomicrograph  by  Wright.     Young  tumor,  parenchyma  in  excess. 


On  two  occasions  I  have  found  adenofibroma  and  intracanalicular  myxoma  in 
the  same  breast. 

^BENIGN  EPITHELIAL  TUMORS. 

Cystic  Adenoma. — I  have  observed  but  five  cases  (1.5  per  cent.).  The  age  of 
onset  varied  from  twenty-eight  to  fifty  years,  the  duration  of  the  encapsulated  tumor 
from  three  months  to  five  years,  in  breasts  which  had  never  been  the  seat  of  lacta- 
tion hypertrophy.  All  were  small,  freely  movable,  encapsulated  tumors.  At  the 
exploratory  incision  they  could  be  recognized  by  the  little  cystic  bulging  from  the 
capsule  (Plate  II,  Fig.  2)  and  by  the  minute  cysts  on  section.     The  stroma  is  scanty. 

Microscopically  the  picture  resembles  senile  parenchymatous  hypertrophy;  there 


PLATE  II. 


Fig.  1. — Small  Intracanaliculak  Myxoma. 
Girl  aged  eighteen,  tumor  eleven  months.      (Halsted's  clinic.) 


Fig.  2. — Encapsulated  Cystic  Adenoma. 
Sketch  from  fresh  tumor.     Female    aged    twenty-six,    tumor    ten    years.     Excision   of   tumor. 

(Halsted's  clinic.) 


Well   six   years. 


BENIGN   TUMORS. 


221 


•t-  .«■       .^»  i.      -<S  ^^    Iff  .  ,        . 


are  adenomatous  areas  (Fig.  450),  areas  of  ectasia  (Fig.  451),  minute  epithelium- 
lined  cysts  (Fig.  453),  and  adenocystic  areas  (Fig.  454). 

The  differential  diagnosis  of  the  benign  cystic  adenoma  from  the  malignant 
adenocarcinoma,  at  the  exploratory  incision,  will  be  discussed  later  (page  227). 

Twice,  in  breasts  removed  for  carcinoma,  I  have  observed  multiple  cystic  ade- 
nomata (Fig.  474) — unilateral  in  one  case,  bilateral  in  the  other.  The  patient  with 
the  unilateral  lesion  has  shown  no  evidence  of  trouble  in  the  remainino^  breast  durinsf 
an  observation  of  six  and  a  half  years  since  operation.  The  patient  with  the  bi- 
lateral lesion,  who  refused  the  removal  of  the  remaining  breast,  died  of  carcinoma 
of  this  breast  five  ancl  a  half  years  after  the  first  operation. 

Cysts  with  Intracystic  Papillomatous  Growths. — The  interesting  fact  in 
the  clinical  history  of  this  benign  cyst  is  the 
discharge  of  blood  from  the  nipple,  which 
is  rarely  absent,  either  in  the  history  or 
at  the  examination.  There  are  eighteen 
observations  (5  per  cent.)  of  the  benign 
form,  while  during  the  same  period  I  have 
records  of  fourteen  cases  in  which  the 
papilloma  had  become  an  adenocarci- 
noma (p.  2.31). 

The  possibility  of  a  malignant  trans- 
formation must  always  be  borne  in  mind. 
The  age  of  onset  is  about  the  same  in 
both  the  benign  and  malignant  form, 
from  twenty-seven  to  sixty-four  years  of 
age.  In  the  benign  cysts  the  tumor  had 
been  present  from  five  to  fifteen  years, 
while  the  longest  duration  of  the  tumor 
in  the  malignant  cyst  was  twenty  years. 
The  duration   of    the    tumor,  therefore. 


J 

( V  A 


m 


i^  ^ 


:0 


'<f. 


^o" 


will  not  aid  in  the  differential  diagnosis. 


Fig.  474. — Cystic  Adenoma. 
Low-power    microscopic    drawing    by    Horn    from 
one  of   multiple  shot-like  tumors  in  a  breast  the  seat 
of  cancer. 


In   both   there   may   be   a   history  of  a 

small  tumor  which  has  remained  quiescent  for  a  number  of  months  or  years,  and 

then  taken  on  rapid  growth. 

As  long,  therefore,  as  the  tumor  has  not  developed  any  clinical  signs  of  malig- 
nancy, the  diagnosis  must  be  made  at  the  exploratory  incision.  In  the  benign  cysts 
the  wall  does  not  differ  from  that  of  a  simple  cyst  (p.  207),  the  contents  are  either 
hemorrhagic  (Fig.  475),  cloudy,  or  clear,  never  thick  and  granular.  On  opening  the 
cyst  and  sponging  out  its  contents  one  can  see  or  feel  a  papilloma  projecting  from  the 
wall  (Fig.  476).  This  papilloma  varies  in  size:  it  may  be  very  small  and  the  cyst 
large,  or  it  may  almost  completely  fill  the  cyst.  Its  surface  appearance  is  lobulated 
and  there  will  be  no  infiltration  of  the  breast  at  the  base  of  the  papilloma  (Fig.  476). 

A  malignant  cyst  may  be  recognized  by  its  thick,  grumous,  granular  contents, 


222 


DISEASES    OF    THE    FEMALE    BREAST, 


by  the  changed  appearance  of  the  papilloma,  or  by  definite  cancer  nodules  of  the 
cyst  wall  (p.  231). 

In  my  experience,  it  is  best  to  remove  the  entire  breast  when  a  benign  cyst  with 
a  papilloma  is  exposed,  because  it  is  usually  situated  in  the  nipple  zone,  and  the 
nipple  must  be  sacrificed.  If  there  is  any  doubt  as  to  its  malignancy,  the  complete 
operation  for  carcinoma  should  be  performed. 

I  have  observed  this  papillomatous  cyst  to  be  multiple  in  one  case,  and  similar 
observations  are  recorded  in  literature. 

Discharge  of  Blood  from  the  Nipple. — In  both  the  benign  and  the  malignant 
papillomatous  cyst  this  has  been  the  symptom  of  onset  in  a  few  cases.  In  the  ma- 
jority the  tumor  has  been  observed  within 
a  year  after  the  discharge  was  first  noticed. 
In  one  case  the  interval  was  three  years;  in 
one  patient  no  tumor  could  be  felt  at  the 
examination.  The  patient  came  to 
the  clinic  because  of  discharge  of 
blood  from  the  nipple,  of  five 
months'  duration.  The  pa- 
pillomatous cysts  were  dis- 
covered at  the  exploratory 
incision. 

I  have  observed  three  pa- 
tients with  discharge  of  blood 
from  one  nipple  which  up  to 
the  present  time  have  shown 
no    evidence    of  tumor.      In 
one   it   is    three   and    a   half 
years   since   the   first   symp- 
tom; in  the  others,  two  years. 
If   there    is    nothing    but 
discharge  of  blood  from  the 
nipple,  I  am  of  the  opinion 
that  such  a  patient  runs  no 
greater  risk  without  operation 
than  a  woman  without  such  a  discharge.     The  probabilities  are  that  a  cyst  will 
develop.     I  presented  the  choice  of  an  exploratory  incision  to  these  three  patients, 

but  did  not  urge  it. 

Carcinoma. 

It  has  been  sufficiently  emphasized  that  the  surgeon  should  train  himself  to 
recognize  the  malignant  epithelial  tumors  of  the  breast  at  the  examination.  "When 
this  is  impossible,  he  should  learn  to  distinguish  the  benign  from  the  malignant  neo- 
plasm at  the  exploratory  incision,  or  from  a  rapidly  frozen  section. 

It  has  been  stated  before  that  when  a  clinical  diagnosis  of  a  malignant  tumor  can 


Fig.  475. — Cyst  with  Intracystic  Papillomatols  Growth. 

Section    through   breast    and    cyst    showing    hemorrhagic    contents 

Female,  aged  fifty-two,  tumor  ten  years. 


CARCINOMA, 


223 


be  made  the  complete  operation  should  be  performed  without  an  exploratory  inci- 
sion.    The  signs  which  allow  such  a  diagnosis  have  been  given. 


Fig.  476. — Section  Through  Breast  and  Cyst  Showing  Papilloma  in  Fig.  47.5. 
The  breast  surrounding  the  cyst  is  senile;  a  few  ducts  beneath  the  nipple  are  dilated. 

In  the  further  discussion  of  carcinoma  the  gross  appearance  of  the  different  forms 
will  be  described,  and  this  description  will  be  the  chief  object  in  view.     For  purposes 


Fig.  477.— Microscopic    Drawing   of  Base  of  Papilloma  in  Fig.  476,  Showing  Cyst  Wall  and  Breast. 


of  prognosis  statistical  figures  as  to  the  curability  of  the  different  forms  of  carcinoma 
will  be  added. 


224  DISEASES   OF   THE   FEMALE    BREAST. 

The  complete  operation  for  carcinoma  should  never  be  restricted,  but  it  is  of 
interest  to  the  surgeon  to  know  the  probable  result. 

Classification  of  Carcinoma. — For  the  purpose  of  diagnosis  from  the  fresh 
appearance  and  for  the  comparative  diagnosis,  carcinoma  of  the  breast  falls  naturally 
into  the  following  groups:  adenocarcinoma,  medullary  carcinoma,  scirrhus,  and 
cancer  cysts. 

Operable  and  Inoperable  Tumors. — In  Halsted's  chnic  of  the  Johns  Hop- 
kins Hospital  about  464  patients  with  primary  carcinoma  of  the  breast  have  been 
admitted.  In  115  (27.5  per  cent.)  the  disease  has  been  inoperable.  Among  these, 
partial  operations  were  performed  in  72  cases  (17.2  per  cent.).  In  every  one  of 
these  cases  there  had  been  undoubtedly  an  operable  period. 

This  large  proportion  of  inoperable  carcinomata  of  the  breast  should  be  reduced 
by  the  education  of  the  public  and  the  profession  to  the  fact  that  every  single  tumor 
of  the  breast  should  be  explored  and  the  indicated  operation  performed  as  soon  as 
possible  after  it  is  observed  by  the  patient. 

The  ultimate  results  in  210  cases  which  have  been  followed  three  years  or  more 
since  complete  operation  show  that  42  per  cent,  have  remained  well  three  years  and 

more.    In  this  number  a  few  have  developed 

recurrences  after  an  interval  of  three  years 

of  apparent  cure,  reducing  the  percentage 

to  35  permanently  cured  at  the  present  time. 

When  the  microscope  has  failed  to  find 

evidence  of  metastasis  to  the  axillary  glands, 

85  per  cent,  remained  well  three  years,  and 

75  per  cent,  were  permanently  cured.     This 

demonstrates  that  absence  of  microscopic 

evidence  of  metastasis  in  the  removed  axil- 

FiG.  478.— CoMEDo-ADENocARciNOMA.  \Qjy  glauds  docs  uot  cxcludc  thc  possiblHty 

Section  of  aieohoi^sp.^^^^^^^  of  Geo.  A.     ^^  ^c^th  withiu,  or  after,  three  years  from 

metastasis. 
When  the  microscope  has  found  metastasis  to  the  axillary  glands,  the  percentage 
of  apparent  three  years'  cure  falls  to  31,  and  permanent  cures  to  24.  When  the 
removed  supraclavicular  glands  showed  metastasis,  the  percentage  of  cures  is  re- 
duced to  10  and  7  respectively.  These  figures  are  given  here  in  order  that  they  may 
be  used  for  comparison  when  we  study  the  percentage  of  inoperable  cases  and  cured 
cases  in  the  different  forms  of  carcinoma. 

Adenocarcinoma. — The  relative  frequency  of  this  variety  is  14.4  per  cent,  of 
all  cases.  The  number  of  inoperable  cases  is  least ;  the  percentage  of  cures,  greatest ; 
the  relative  number  of  cases  which  have  been  clinically  doubtful  and  in  which  an 
exploratory  incision  has  been  made,  largest. 

This  gives  an  opportunity  to  study  the  effect  of  an  exploratory  incision  into  a 
carcinoma.  Among  ten  cases,  in  w^iich  three  years  or  more  have  passed  since  the 
operation,  nine  are  apparently  well — 90  per  cent. ;  one  case  remained  well  four  years 


CARCINOMA. 


225 


and  died  of  internal  metastasis  later.  In  this  group  the  percentage  of  negative 
microscopic  examination  of  the  axillary  glands  is  greatest. 

The  age  of  onset  in  this  group  is  between  forty  and  fifty;  in  one  case  the  patient 
was  aged  twenty-seven,  in  one  thirty-two;  the  oldest  patient  was  seventy.  Adeno- 
carcinoma, therefore,  may  be  met  with  at  any  age  over  twenty-five. 

Adenocarcinoma,  for  the  purpose  of  the  description  of  its  fresh  appearance, 
should  be  divided  into  the  following  varieties:  the  comedo,  or  duct  cancer;  the 
colloid;  the  adenocystic,  and  the  malignant  intracystic  papilloma. 

Each  one  of  these  varieties  may  be  pure,  or  the  tumor  may  be  mixed  with  scir- 
rhus  or  medullary, carcinoma. 

The  adejiocarcinoma  comedo  begins  as  a  circumscribed  tumor.  At  the  explora- 
tory incision  there  is  no  capsule.  The  cut  surface  shows  trabeculse  of  fibrous  tissue 
in  the  meshes  of  which  are  round,  granular  areas,  from  the  center  of  which  worm- 
like comedo-bodies  can  be  expressed 
(Figs.  478,  479,  and  480).  The  appear- 
ance of  this  tumor  is  absolutelv  charac- 


FlG.    479. COMEDO-ADENOCARCINOMA. 

Photograph  from  Kaiserhng  specimen,  showing  skin, 
fat,  tumor,  muscle  (by  Schapiro). 


Fig.  480. — Recurrent  Comedo-adenocarcinoma. 

Photograph  of  section  through  alcohol  specimen, 
showing  small  fungous  tumor,  skin,  fat,  and  muscle. 
See  Fig.  484.     Photograph  by  A.  S.  .Murray. 


teristic  and  cannot  be  mistaken  for  any  benign  lesion.  Microscopically  the  round, 
large  alveoli  are  filled  with  epithelial  cells  of  the  morphology  of  the  basal  cell  of 
the  duct;   the  central  cells  show  necrosis  (Figs.  481  and  482). 

This  tumor,  in  its  early  stage,  is  clinically  doubtful.  In  its  further  growth  it 
infiltrates  to  the  skin  and  may  ulcerate,  producing  a  fungous  growth  (Figs.  483  and 
484).  Among  twelve  cases  of  the  pure  type  I  have  yet  to  observe  metastasis  to  the 
axilla.  All  so  far  have  been  permanently  cured.  In  one  the  tumor  was  bilateral 
(specimen  sent  me  by  McCallum,  of  Canada).  The  only  positive  cure  of  a  re- 
current carcinoma  belongs  to  this  group.  The  recurrent  tumor  was  a  fungus  (Fig. 
484). 

One  of  these  patients  who  refused  the  removal  of  the  other  breast  died  five  years 
later  of  cancer  of  this  breast.  This  patient  had  multiple  shot-like  tumors  (Fig.  474) 
in  both  breasts,  one  of  which  had  taken  on  recent  growth.     The  growing  tumor 

AOL.  II 15 


226  DISEASES    OF   THE   FEMALE   BREAST. 

was   an   adenocarcinoma-comedo ;    the  others,  cystic  adenomata.     It  was  for  this 
reason  that  I  advised,  after  the  first  operation,  the  removal  of  the  other  breast. 

The  comedo  type  is  the  most  common  form  of  adenocarcinoma.  The  cells  in 
the  tumor  just  described  are  of  the  basal  type  and  arranged  in  sohd  masses  in  the 
long  tubules,  and,  according  to  Krompecher,  would  be  called  adenocarcinoma  haso- 
cellulare  solidum.  In  a  few  cases  the  cells  have  had  a  special  arrangement  (Fig.  485), 
and  Krompecher  calls  this  arrangement  adenoides.  It  differs  in  the  gross  from  the 
solidum  in  the  absence  of  the  central  necrosis.  Among  three  cases — one  with 
metastasis  to  the  axilla — in  which  the  complete  operation  was  performed,  all  patients 

'^^M^^     '■^■'  -    .•>j^^'®^^<5^-:;   .  '    -'''•■■'■'.), 


m^ 


M 


«.v»i  -ij^: 


^t; 

:^"-l  ''"*^^/ 


Fig.  481. — Comedo-adenocarcinoma. 
Microscopic  drawing  by  Horn. 

have  remained  well  from  five  to  seven  years.  In  one  who  had  allowed  the  removal 
of  only  the  breast,  there  was  later  recurrence  and  death.  This  observation  is  one 
among  a  number  of  others  of  whtch  I  have  records  in  the  laboratory,  and  which 
demonstrate  the  insufficiency  of  an  incomplete  operation  even  in  this,  the  least  malig- 
nant form  of  cancer. 

The  mixed  types  of  this  adenocarcinoma-comedo,  with  scirrhus  or  medullary, 
have  always  been  clinically  malignant,  and  the  probability  of  a  cure  conforms  to 
that  in  medullary  or  scirrhous  carcinoma.  Among  our  eight  cases  all  had  metastasis 
to  the  axilla;  four  were  cured  three  years,  but  all  of  these  developed  late  metastases. 

The  age  of  onset  has  been  between  forty-two  and  sixty-five,  that  is,  in  the  breasts 


CARCINOMA.  227 

of  older-  women.     Although  the  tumor  is  apparently  a  duct  cancer,  it  has  never  been 


Fig.  482. — Comedo-adenocarcinoma. 
Photomicrograph  by  Wright.     See  Fig.  480. 


observed  in  the  nipple  zone.     In  the  large  majority  of  cases  the  remainder  of  the 
breast  is  senile.     In  a  few  the  breast  has  shown  senile  parenchymatous  hypertrophy, 
so  common  at  this  age ;  in  one  patient  there  were  multiple 
cystic  adenomata;  in  this  and  one  other  case  the  disease 
was  bilateral. 


Fig.  48.3. — Comedo-adenocarcinoma,  Becoming  Medullary  Carcinoma. 
Huge  fungous  tumor.     Woman,  aged   fifty,  tumor  three    years;    fungus    nine 
months.     Cured  three  years.     Halsted's  clinic. 


Colloid  Adenocarcinoma. — In  its  onset  this  is  a  small, 
circumscribed,  clinically  doubtful  tumor.  At  the  ex- 
ploratory incision  there  is  a  thin  capsule  (Fig.  486),  and 
one  sees  between  the  narrow,  fibrous  trabeculae  bulging, 
pink,  gelatinous  lobules — an  appearance  which  should 
not  be  mistaken  for  any  other  tumor  (Fig.  487). 

Three  cases  have  been  observed  in  Halsted's  clinic,  one  a  recurrent  tumor,  all 
cured  by  the  complete  operation.     I  have  tissues  from  four  other  cases. 


Fig.  484. — Recurrent  Adeno- 
carcinoma; Fungous  Tumor. 
For  gross  and  microscopic 
picture  see  Figs.  480  and  482. 
Photograph  by  Cushing.  Hal- 
sted's clinic.  Female,  aged 
sixty-five,  disease  two  years; 
excision  of  tumor  only,  eight 
months  after  onset;  immediate 
recurrence;  complete  Halsted 
operation;  no  metastasis  to  ax- 
illa.    Well  ten  years. 


228 


DISEASES    OF   THE   FEMALE    BREAST. 


I  feel  that  the  operation  should  never  be  restricted  in  this  form  of  cancer,  even 
in  its  early,  pure  state.     The  study  of  the  recurrent  case  in  the  surgical  clinic  and 


Fig.  485. — Comedo-adenocarcinoma  (Adenoides  Type). 
Photomicrograph  by  Wright. 

two  outside  recurrent  cases  indicates  that  the  origin  may  be  multicentric,  and  the 
recurrences  are  explained  by  secondary  tumors  in  the  breast  left  behind. 

This  tumor  may  become  a  scirrhous  carcinoma — one  observation,  not  cured. 


Fig.  486. — Colloid  Adenocarcinoma. 
Photograph    from    fresh    specimen    by    Schmitz.     Circumscribed  tumor  in  a  fairly  normal  breast.     Female, 
aged  forty-three,  tumor   nine  months;   clinically   malignant;    diagnosis  based   on   shortening  of  skin   trabeculre. 
Complete  operation;    no  metastasis  to  axilla.     Cured  four  years. 

It  is  a  tumor  of  the  senile  breast.     The  age  of  onset  varies  between  thirty-nine 
and  sixty-nine.     It  is  of  .slow  growth.     The  clinically  benign  tumors  have  been  of 


CARCINOMA. 


229 


less  than  one  year's  duration.  In  one  in  which  there  was  an  ulcer,  the  tumor  of 
seven  years'  duration  was  still  circumscribed,  and  there  was  no  metastasis  to  the 
axilla.  In  one  the  tumor  had  been  quiescent  for  seven  years,  and  then  took  on  ac- 
tivity; three  years  later  the  skin  was  adherent  and  the  nipple  retracted. 


Fig.  487. — Colloid  Adenocarcinoma. 
Photomicrograph  of  tumor  in  Fig.  486  (by  Wright). 


Cystic  Adenocarcinoma. — This  form  is  better  described  in  two  groups:  the  first, 
a  circumscribed  tumor,  which  may  be  looked  upon  as  a  malignant  cystic  adenoma; 
the  second,  the  adenocarcinoma  arising  in  senile  parenchymatous  hypertrophy. 

Circumscribed  Forvi. — The  malignant  cystic  adenoma,  like  its  benign  prototype 


Fig.  488. — Adenocarcinoma,  Adenocystic  Type;    Circumscribed  Tumor. 
Photograph   of   alcohol   specimen   by  A.  S.    Murray.     Clinically   malignant  (adherent   skin).     No   metastasis   to 

axilla.     Cured  four  years. 

(Plate  II,  Fig.  2)  is  a  relatively  infrequent  tumor.  When  clinically  benign,  it  can  be 
differentiated  from  the  adenoma  by  the  absence  of  a  capsule;  on  section,  there  is  more 
fibrous  tissue,  very  few  cysts,  but  granular  areas  without  cyst  walls,  which  express 


230 


DISEASES    OF   THE   FEMALE    BREAST. 


on  pressure  (Fig.  488).  Two  cases  of  the  pure  type  (one  with  metastasis  to  the 
axilla)  have  remained  well  eleven  years  since  operation.  One  w^ho  allowed  only 
the  excision  of  the  breast  returned  in  two  years  with  metastatic  axillary  glands,  and 
again  refused  operation — another  observation  of  the  danger  of  incomplete  removal 

of  a  cancer  of  the  breast.  Two  cases  of  this  type 
mixed  with  scirrhus  originated  in  the  lactating 
breast;  neither  was  cured. 

The  pure  type  has  appeared  in  the  senile 
breast.  The  patients'  ages  varied  from  fifty-two 
to  sixty-four  at  onset.  The  duration  of  the  tumors 
has  varied  from  two  to  ten  years.  Only  the 
mass  of  two  years'  duration  was  clinically  benign. 
The  age  of  the  patients  in  whom  the  tumors  ap- 
peared during  lactation  was  thirty-eight  and  forty- 
five  ;  in  both  the  mass  had  been  treated  for  chronic 
mastitis  for  eight  months,  and  with  massage! 

Like  the  adenocarcinoma-comedo,  the  circum- 
scribed cystic  adenoma  may,  in  its  growth,  infil- 
trate skin  and  muscle  (Fig.  489),  and  yet  such  an 
extensive    local    infiltration    is    not   incompatible 
with  a  permanent  cure.     It  is  in  this  form  of  carcinoma  that  more  extensive  local 
operations  with  resection  of  ribs  and  intercostal  muscles  are  justifiable. 

The  Diffuse  Form. — I  have  discussed  the  recognition  of  carcinoma  in  senile 
parenchymatous  hypertrophy   (page  201).     Four  cases  in  which  carcinoma  was 


Fig.  489. — Adenocarcinoma,  Adeno- 
CYSTic  Type. 
Photograph  of  patient  showing  in- 
volvement of  skin.  In  this  ease  the 
tumor  infiltrated  the  pectoral  muscle; 
there  was  no  metastasis  to  axilla,  and 
the  patient  has  remained  well  nine  years 
after  the  complete  operation.  Halsted's 
clinic. 


Fig.  490. — Adenocarcinoma  in  Senile  Parenchymatous  Hypertrophy. 
Showing  one  cyst  with  intracystic  papillomatous  growth.     Metastasis  to  axilla.     Photograph  from  painting  by 

Miss  Hayes,  from  section  through  breast. 


early  (one  with  metastasis  to  the  axilla)  have  been  cured  four  to  fourteen  years.  In 
one  the  breast  only  was  removed  (Plate  III);  this  patient  has  remained  well  over 
four  years.  This  is  our  only  example  of  a  carcinoma  cured  by  an  incomplete  opera- 
tion.    It  was  interesting  to  note  that  two  tumors  of  this  type  mixed  with  scirrhus, 


PLATE  III. 


Medullary  Carcinoma,  Adenocystic  Typk. 
From  painting  by  Horn,  Halsted's  clinic.     Female  aged  forty-three,  tumor  two  years;    metastasis    to    axilla. 

Cured  four  years.     (Original,  Bloodgood.) 


/ 


CARCINOMA. 


231 


both  with  metastasis  to  the  axilla,  have  been  cured,  one  not  cured  (Figs.  490,  491, 
492),  giving  a  percentage  of  66. 

The  patients,  at  the  onset  of  the  disease,  have  varied  in  age  from  thirty-six  to 
fifty-five.  In  the  early  type  the  duration  of  growth  varied  from  two  weeks  to  eight 
months;  in  the  mixed,  from  four  to  eight  months. 

Palpable  masses  of  durations  of  more  than  eight  months  have  not  been  observed. 
The  evidence,  then,  is  that  senile  parenchymatous  hypertrophy  which  has  reached 
a  stage  in  which  a  quadrant  of  the  breast  is  involved  always  becomes  cancer,  and 
may  do  so  in  four  weeks,  usually  within  six  months.     If  there  is  no  metastasis  to  the 


Fig.  491. — Photomicrograph  (Wright)  from  Tumor  in  Fig.  490. 
Showing  cystic  adenocarcinoma  and  infiltration  of  breast  stroma  and  fat  with  cancer  epithelium. 

axilla,  the  prognosis  is  100  per  cent,  of  cures;   if  mixed  with  scirrhus  and  there  is 
metastasis  to  the  axilla,  the  prognosis  is  66  per  cent,  of  cures. 

Adenocarcinoma  Beginning  in  a  Cyst  with  an  Intracystic  Papilloma. — The  benign 
prototype  has  been  discussed.  The  malignant  form  occurs  with  equal  frequency. 
When  the  tumor  cannot  be  recognized  as  malignant  (Fig.  493)  at  the  examination, 
there  should  be  little  difficulty  at  the  exploration.  The  bloody  contents  of  the  cyst 
would  not  aid,  because  this  is  present  in  the  benign  form;  but  the  contents  has 
usually  been  granular;  the  mulberry  surface  of  the  papilloma  is  lost  and  replaced 
by  a  fungous  growth  resembling  a  medullary  carcinoma  (Figs.  494,  495,  496).  I 
believe  that  in  every  case  the  malignant  nature  can  be  recognized  on  opening  the  cyst. 
It  will  not  be  necessary  to  cut  through  the  fungous  growth  and  show  its  infiltration 


232 


DISEASES    OF   THE    FEMALE    BREAST. 


into  the  surrounding  breast.  The  prognosis,  in  the  early  cases,  is  good :  five  cures 
out  of  six  cases — 83  per  cent.  In  one  of  the  cured  cases  the  axillary  glands  showed 
metastasis.  In  the  case  not  cured  the  axilla  was  involved.  In  a  seventh  observa- 
tion, in  which  only  the  breast  was  removed,  there  was  local  recurrence  and  death 
from  internal  metastasis. 

When  the  entire  breast  about  the  cyst  has  become  infiltrated  with  carcinoma, 
the  prognosis  is  bad.     We  have  observed  no  cures. 

This  malignant  cyst  has  been  observed  in  younger  women — one  aged  twenty- 
seven.  Usually  the  age  of  onset  is  over  forty.  The  tumors  may  be  of  long  duration 
— four  to  twenty  years;   usually,  however,  they  are  of  shorter  duration — less  than 


....,, 


Fig.  492. — Photomicrograph  (Wright)  to  Illustrate  Adenocarcinoma  Becoming  Scirrhus. 


two  years.  A  discharge  of  blood  from  the  nipple  is  frequently  noted  in  the  clinical 
history.  In  the  older  cases  the  breasts  are  senile;  in  the  younger — about  forty — 
evidence  of  senile  parenchymatous  hypertrophy  has  been  present;  in  one  there  were 
multiple  cystic  adenomata. 

This  study  of  adenocarcinoma  is  our  best  evidence  that  a  single  tumor  in  the 
breast  should  always  be  explored  and  that  an  incomplete  operation  for  carcinoma 
should  never  be  done.  It  is  in  this  group  that  cures  have  been  accomplished  in 
tumors  of  long  duration,  even  though  ulcers  and  fungi  had  formed.  The  duration 
of  life  is  long,  as  illustrated  in  one  of  the  incomplete  operations,  after  which  the 
patient  lived  more  than  twelve  years,  with  evidence  of  recurrence  and  general 


CARCINOMA. 


233 


metastasis,  even  to  the  scalp,  which  had  been  present  for  at  least  six  years  before 
death. 

Medullary  Carcinoma. — The  relative  frequency  is  slightly  less  than  that  of 
adenocarcinoma — 13  per  cent.  The  probability  of  a  cure  for  three  years  is  about 
37  per  cent. ;  about  equal  to  that  of  the  small  infiltrating  scirrhus  and  slightly  less 
than  the  circumscribed,  scirrhus.  Although  the  tumor  grows  rapidly  locally,  it  does 
not  infiltrate,  like  the  scirrhus,  and  the  -proportion  of  inoperable  cases  is  relatively 
very  small — only  a  little  greater  than  of  adenocarcinoma. 

The  age  of  onset  is  more  variable  than  in  any  other  group — from  twenty-eight 
to  sixty-five.     The  cancer  of  the  lactating  breast  is  usually  of  the  medullary  type. 


Fig.  493. — Cyst  with  Malignant  Papilloma. 
Photograph  of  patient,  Halsted's   clinic.    Female,  aged  seventy-two,  tumor  nineteen  months.     Chnically  malig- 
nant (infiltration  of  skin);   no  metastasis  to  axilla.     Cured  five  years. 


About  7  per  cent,  of  the  medullary  tumors  have  been  clinically  doubtful  and 
were  only  recognized  at  the  exploratory  incision. 

This  tumor,  in  its  onset,  is  small  and  circumscribed,  rarely  infiltrating,  like  a 
scirrhus.  At  the  exploratory  incision  there  is  no  capsule,  and  the  soft,  finely  granu- 
lar, friable  tumor  should  never  be  mistaken  for  a  benign  lesion.  Necrosis  is  always 
a  prominent  feature  of  the  fresh  appearance.  In  some  of  the  tumors  the  stroma 
cannot  be  made  out  with  the  naked  eye,  and  they  look  like  sarcoma;  in  others  the 
stroma  is  quite  distinct. 

For  the  purposes  of  prognosis  I  have  divided  the  medullary  tumor  into  the  follow- 
ing groups : 


234  DISEASES    OF   THE    FEMALE    BREAST. 

Medullary   Mixed  with  Adenocarcinoma-comedo. — In   this   tumor  the   typical 


Fig.  494. — Sketch  of  Section  Through  Wall  of  Cyst  in  Fig.  493. 
P,  Papilloma;   A',  cartcer  in  wall.     Drawing  by  Horn,  Halsted's  clinic. 

comedones  can  be  expressed  in  a  few  areas  and  can  be  made  out  in  the  microscopic 
section.     The  relative  prognosis  is  better — 66  per  cent.     The  age  of  the  patients 


Fig.  495. — Malignant  Papillary  Cyst. 
Photograph  from  painting  by  Horn,  Halsted's  clinic. 


is  similar  to  that  in  the  comedo  group,  and  the  breast  is  senile.     The  tumor  may 
produce  a  fungus  (Fig.  483) 


CARCINOMA. 


235 


Medullary  Mixed  with  Adenocarcinoma  Cystic. — This  may  be  recognized  in  the 
fresh  by  the  small  cysts  and  spongy  areas  (Plate  III).  The  probability  of  a  cure  is 
80  per  cent.     All  were  clinically  malignant  (Fig.  497). 


m\>^Wf^^^^  >, 


Fig.  496. — Photomicrograph  (Wright)  of  Adenocarcinoma  in  Wall  of  Cyst.     (See  Fig.  494,  at  A'.) 

In  these  two  groups  in  which  the  medullary  carcinoma  may  have  been  originally 
an  adenoma  or  adenocarcinoma,  the  duration  of  the  tumor  in  some  of  the  cases — 


\ 


Fig.  497. — Medullary  Carcixoma. 
Photograph  of  patient  showing  involvement  of  skin. 


one,  two,  three,  and  four  years — suggests  an  origin  in  a  cancer  of  a  relatively  slow 
growth. 


236 


DISEASES    OF   THE    FEMALE    BREAST. 


If  these  two  groups  of  medullary  carcinoma  should  be  placed  with  adenocarci- 
noma, it  would  make  the  prognosis  for  medullary  tumors  much  worse. 


) 


r 


Fig.  498. — Medullary  Carcinoma,  Hemorrhagic  Type. 
Photograph  of  patient,  Halsted's  clinic.     Female,  aged  fifty-eight,  tumor  four  years;  metastasis  to  axilla.     Cured 


nine  years. 


Hemorrhagic  Medullary  Carcinoma. — In   the  fresh  this  circumscribed    tumor 
is  mottled  with  areas  of  old  and  fresh  hemorrhage,  like  a  thyroid  tumor,  and  the 


■^■"^-^  ^ '  > 


Fig.  499. — Photomicrograph  (Wright)  of  Medullary  Carcinoma. 


evidence  of  blood  can  be  demonstrated  under  the  microscope,  both  in  the  stroma 
and  in  the  epithelial  alveoli.     In  some  of  the  cases  the  histology  resembles  an  endo- 


CARCINOMA.  237 

thelioma.  The  prognosis  is  good — SO  per  cent,  of  three-year  cures,  60  per  cent, 
permanent  cures  (Fig.  498).  It  has  been  observed  as  a  bilateral  tumor  and  in  the 
lactating  breast.  The  age  of  the  women  has  varied  from  twenty-eight  to  sixty-five. 
The  tumors  were  of  four  months'  to  four  years'  duration.  In  over  50  per  cent,  of 
the  cases  the  axilla  was  not  involved.  Two  cases  were  clinically  benign  and  an 
exploratory  incision  was  necessary. 

Pure  Medullary  Carcinoma. — A  soft  tumor  with  sufficient  stroma  to  be  recog- 
nized with  the  naked  eye,  between  which  the  tissue  is  granular,  friable,  and  can  be 
expressed  on  pressure.  Under  the  microscope  the  epithelial  cells  are  large  (of  the 
glandular  type)  and  show  no  special  arrangement  in  the  alveolus  (Figs.  499  and 


^  t*^    ,=•' 


K.y^ 


^■&Z 


^'"^^^%  ^  - 
Fig.  500. — Microscopic   DRAWirsG   of   Medullary  Carcinoma. 

500).  The  pro])ability  of  a  cure  for  three  years  is  only  25  per  cent.  In  none  of  the 
cured  cases  did  the  axilla  show  metastasis.  The  age  of  onset  varied  from  twenty- 
eight  to  sixty.  The  majority  of  the  tumors  were  of  but  a  few  months'  duration, 
and  all,  with  one  exception,  of  less  than  one  year.  In  two  cases  the  tumor  was  in  a 
lactating  breast  (Figs.  501  and  502),  in  the  remainder  the  breast  was  senile.  In 
about  12  per  cent,  of  the  cases  the  tumor  was  clinically  benign,  and  in  10  per  cent, 
the  lesion  was  bilateral. 

Medullary   Carcinoma  Resemhling  Sarcoma. — In   the  fresh   these   tumors   are 
so  cellular  that  they  cannot  be  distinguished  from  a  sarcoma.     They  are  of  rapid 


238 


DISEASES    OF   THE   FEMALE    BREAST. 


Fig.   501. — Medullary  Carclnoma  in  Laciatixg  Breast. 
Female,  aged  forty-four,   tumor  two  j-ears;    metastasis  to  axilla      Death  of  mediastinal  metastasis  two  years 

and  eight  months.     Halsted's  clinic. 


Fig.  502. — Medullary  Carcinoma  ix  Lactatixg  Breast. 
Photograph  from  fresh  specimen  (Schapiro),  section  through  breast. 


CARCINOMA. 


239 


Fig.  503. — Medullary  Carcinoma,  like  Sarcoma. 
Not  cured.     Photograph  of  patient,  Halsted's  cHnic. 


Fig.  504. — Medullary  Carcinoma,  like  Sarcoma. 
Not  cured.     Photograph  of  patient,  Halsted".s  cHnic. 


240 


DISEASES    OF   THE   FEMALE    BREAST. 


growth  (Figs.  503  and  504),  give  metastasis  to  the  axilla  early,  and  up  to  the  present 
time  have  been  incurable. 

Scirrhous  Carcinoma. — For  the  purpose  of  diagnosis  I  have  divided  scirrhus 


Fig.  505. — Circumscribed  Scirrhus,  Base  of  Breast,  Infiltrating  Pectoral  Fascia;  Breast  Normal. 
Photograph  from  fresh  tissue,  section  through  nipple,  breast,  and  muscle.     Recent  case. 

into  three  groups:  the  circumscribed  (Figs.  505,  506,  and  Plate  IV,  Fig.  1),  the  small 
(Figs.  507-510,  and  Plate  IV,  Fig.  2),  and  the  large  infiltrating  scirrhus  (Figs.  511, 


--l^T-^.-T 


J-jCh^        «* 


v: 


S^' 


■^^i 


'^^'^^ 


Fig.  506. ^Circumscribed  Scirrhus. 
Microscopic  drawing  by  Horn,  Halsted's  clinic.     Periphery  of  tumor  cellular,  center  fibrous. 


512,  513,  514,  515,  516).  The  fresh  appearance  of  a  scirrhous  carcinoma,  whether 
circumscribed  or  infiltrating,  small  or  large,  is  the  same.  Perhaps  its  most  charac- 
teristic feature  is  the  gritty  sensation  which  it  gives  to  the  knife,  or  to  the  palpating 


PLATE  IV. 


Fig.  1. — Circumscribed  Scikrhus  in  Periphery  of  Breast,  Infiltrating  Fat  Beneath  Skin. 
The  breast  is  fibrous  and  senile,  and  there  are  a  few  dilated  ducts.     Female  aged  seventy,  tumor  three  months; 
malignant,  based  on  atrophy  of  subcutaneous  fat  and  retraction  of  nipple.     Complete  operation;    metastasis  to 
axilla.     Death  of  regionary  recurrence  three  years.      (Halsted's  clinic.) 


Fig.  2. — Small,  Infiltrating  Scirrhus. 
Painting  from  fresh  specimen,  illustrating  star-like  tumor,  dimpling  skin,  retracting  nipple,  infiltrating   muscle; 

breast  senile. 


CARCINOMA. 


241 


finger  when  an  exploratory  incision  is  necessary  to  make  the  diagnosis.  I  believe 
a  surgeon  should  educate  himself  to  recognize  cancer  by  the  sensation  it  gives  to 
the  knife  or  his  finger. 

The  fresh  appearance  of  scirrhus  differs.  If  the  alveoli  of  epithelial  cells  are 
comparatively  large,  with  some  necrosis,  and  the  stroma  quite  fibrous  (the  fibrous 
form  of  scirrhus,  Fig.  508),  the  yellow  dots  and  lines  in  the  fibrous  trabeculae  cannot 
be  mistaken  for  any  other  disease.  However,  when  the  stroma  is  young,  cellular 
connective  tissue,  and  the  epithelial  cells  are  in  small  alveoli,  the  surface  section 
shows  very  few  distinct  markings,  and  might  be  mistaken  for  inflammatory  tissue. 


Fig.  507. — Small  Infiltrating  Scirrhus. 
Photograph  showing  early  dimpHng  of  skin;   tumor 
present    but    a    few    weeks    in    axillary    quadrant. 
Photograph  by  Schapiro. 


Fig.  508. — Small  Infiltrating  Scirrhus,  Fibrous 
Type,  Occupying  Central  Nipple  Zone. 
Photograph  from  fresh  tissue  (Schapiro),  section 
through  nipple,  breast,  and  muscle.  Note  star-like  con- 
traction of  surrounding  tissue  and  the  white  dots  and 
lines  indicating  epithelial  necrosis.  Patient,  aged  fifty- 
four,  tumor  six  months;  induration  in  center  of  breast 
with  retraction  of  nipple;  metastasis  to  axilla  and 
muscle.     Recent  case. 


This  is  the  cellular  type  of  scirrhus  (Fig.  517).  Its  grittiness  distinguishes  it  from 
inflammatory  tissue. 

We  have  ol)served  a  few  scirrhous  tumors  under  thirty — the  youngest  patient  was 
twentv.  The  remainder  are  scattered  between  the  ages  of  thirtv  and  seventv-three. 
Scirrhous  carcinoma  is  the  most  common  tumor  of  the  breast  after  sixty. 

A  scirrhous  carcinoma,  in  my  experience,  assumes  a  clinical  picture  of  malignancy 
within  one  year  (Fig.  507).  We  have  had  a  few  exceptions.  One,  of  five  years' 
duration,  a  small  infiltrating  scirrhus,  was  still  clinically  doubtful,  and  was  not 
recognized  until  the  exploratory  incision  was  made. 

VOL.   II 16 


242 


DISEASES    OF   THE    FEMALE   BREAST. 


The  inoperable  carcinomata  belong  chiefly  to  the  group  of  large  infiltrating  scir- 
rhi.     Of  all  forms  of  cancer,  about  70  per  cent,  are  scirrhus.     The  small  infiltrating 


^^ 


r.-.C 


'*.  ,«t  ^   "its'- r^^.'^^^i'i5*?s     ^^ 


Fig.  509. — Scirrhous  Carcinoma. 
Photomicrograph  (Wright). 


scirrhus  is  the  most  frequent — 31  per  cent. ;  the  large,  29  per  cent, ;  and  the  circum- 
scribed, but  10  per  cent.  Only  18  per  cent,  of  the  large  infiltrating  tumors  have 
been  cured  three  years — 37  per  cent,  of  the  small  tumors  and  42  per  cent,  of  the 


Fig.   510. — Small   Infiltrating   Scirrhus  in   Lower  Periphery  op  Breast. 
Photograph  (Schapiro)  to  show  adherent  skin;    position  of  tumor  unusual. 


circumscribed  variety.     The  prognosis  for  a  scirrhous  carcinoma  is,  therefore,  worse 
than  that  for  the  medullary.     Late  metastases  are  most  frec|uent  in  this  group. 


CARCINOMA. 


243 


Fig.  511. — Lakge  Infiltrating  Scirrhus. 
Photograph  of  patient  to  illustrate  retraction  of  nipple  and  dimpling  of   skin.     Patient,  aged  forty-seven, 
tumor  eighteen  months.     Operation  complete;  no  metastasis  to  axilla.     Apparently  well  seven  years  and  four 
months;  died  with  symptoms  of  brain  metastasis  and  fracture  of  neck  of  femur.     Halsted's  clinic. 


Pig.   512. — Large   Infiltrating  Scirrhus. 
Photograph  of  patient  to  show  retraction  of  nipple,  dimpling  of  skin,  slight  atrophy  of  breast,  retraction 
of  breast  to  chest  wall.     Patient,  aged  forty-three,  tumor  ten  months;  complete  operation;  metastasis  to  axilla  and 
neck.    Death  two  years  and  six  months;  no  external  recurrence;  symptoms  of  internal  metastasis.    Halsted's  clinic. 


244 


DISEASES    or   THE    FEMALE    BREAST. 


Fig.  513. — Large  Infiltrating  Scirrhus. 
Photograph  to  illustrate  retraction  of  nipple,  lines  of  carcinoma  infiltration  radiating  from  nipple  in  skin; 
slight  hypertrophy  of  breast;    retraction  of  breast  on  chest  wall.     Patient,  aged  forty-two,  tumor  one  and  a  half 
years.     Complete  operation;  metastasis  to  axilla  and  neck;  local  recurrence  in  scar  in  one  year;  death.     Halsted's 
clinic. 


Fig.   514. — Large   Infiltrating  Scirrhus. 
Demonstrating  the  extreme  infiltration  of  breast  and  skin;  radiating  cutaneous  and  subcutaneous  involvement 
most  marked  in  the  upper  and  inner  quadrant.     Complete  operation  impossible.     Death  forty-eight  days  after 
operation  of  general  carcinosis.     Age,  forty-six,  tumor  six  months.     An  example  of  the  most  rapidly  growing  and 
fatal  form  of  carcinoma.     Halsted's  clinic. 


CARCINOMA. 


245 


I  am  not  prepared  to  state  positively  at  this  time,  but  my  observations  seem  to 
demonstrate  that  the  morphology  of  the  cell  in  scirrhous  carcinoma  has  a  definite 
relation  to  its  curability.  In  the  majority  of  the  permanently  cured  cases  the  cell 
is  of  the  basal  type,  and  the  tumor  has  originated  in  senile  breasts  of  older  women. 


Fig.  515. — Large  Infiltrating  Scirrhus. 
Photograph  of  section  through  breast  and  muscle  of  specimen  in  Fig.  514,  by  A.  S.  Murray. 

Circumscribed  Scirrhus. — Judging  from  the  specimens  sent  to  my  laboratory 
the  circumscribed  scirrhous  carcinoma  is  frequently  mistaken  for  adenofibroma. 
I  have  a  number  of  specimens  in  which  this  malignant  tumor  was  excised  on  the 
diagnosis  of  a  benign  adenofibroma.     In  the  majority  of  these  cases  the  complete 


Fig.  516. — Large  Infiltrating  Scirrhus. 
Photograph  of  fresh  tissue,  section   through   nipple,  breast,  and   muscle  (Schapiro).     It  illustrates  the  direct 
infiltration   of  the  skin  and  nipple;   a  large  zone  of  the  skin  about  the  nipple  is  involved;    dilatation  of  ducts. 
Hopeless  case. 

operation  was  performed  later,  after  the  microscopic  demonstration  of  its  malig- 
nancy in  the  laboratory.  As  far  as  I  have  been  able  to  ascertain,  none  of  these 
patients  has  been  cured.  Less  frequently  a  benign  fibroadenoma  has  been  treated 
on  the  diagnosis  of  a  scirrhous  carcinoma. 


246 


DISEASES    OF   THE   FEMALE   BREAST. 


In  the  clinically  doubtful  tumors,  as  has  been  discussed  (page  187),  there  should 
be  no  difficulty  in  distinguishing  the  encapsulated,  hard  fibroadenoma  from  the 
circumscribed  scirrhus,  I  should  advise,  however,  if  there  be  any  doubt  and  the 
patient  is  over  thirty-five,  the  performance  of  the  complete  operation  for  cancer. 
I  wish  to  warn  against  the  use  of  the  frozen  section  to  differentiate  the  adenofibroma 
from  the  circumscribed  scirrhus.  It  is  much  more  difficult  than  from  the  fresh 
appearances.  The  irregular  masses  of  atrophying  epithelial  cells  in  the  old  fibrous 
adenofibroma  at  first  sight  give  the  impression  of  cancer  cells  in  fibrous  stroma. 

Atrophic  Scirrhus. — In  about  3  per  cent,  of  all  scirrhous  carcinomata  the  tumor 
situated  beneath  or  near  the  nipple  is  of  very  slow  growth  and  associated  wdth  almost 
complete  atrophy  of  the  breast.  If  no  operation  is  performed,  the  patients  have 
been  observed  to  live  fifteen  years;  in  my  own  observation  not  longer.  The  very 
late  deaths — ten  to  fifteen  years  after  operation — are  observed  in  this  type  of 
tumor.  I  can  find  no  evidence  to  support  the  general  opinion  that  operation  is 
contraindicated.     In  our  few  cases  there  is  no  e^ddence  that  it  shortened  life. 

There  must  be  a  period  in  the  disease  in 
which  complete  removal  will  accomplish  a 
cure. 

Cancer  Cysts. — These  are  the  most  in- 
frequent tumors  of  the  breast — 2.7  per  cent, 
of  all  cases.  Fifty  per  cent,  have  been 
clinically  doubtful  (Fig.  517)  and  explora- 
tory incision  had  to  be  made;  and  it  is 
very  important  to  note  that  in  all  except 
one  the  diagnosis  was  not  made,  but  only 
the  cyst  was  excised,  and  later,  upon  micro- 
scopic examination  of  the  cyst  wall,  a  cancer 
was  recognized  and  the  complete  operation  performed. 

Only  one  of  these  cases  is  living,  and  as  there  is  no  pathologic  report,  the  correct 
diagnosis  may  be  questioned. 

Cystic  Tumors  of  the  Breast. — The  recognition,  at  the  exploratory  incision,  of 
the  solid  tumors  of  the  breast,  has  been  fully  discussed,  and  on  the  whole  is  less 
difficult  than  of  the  cystic.  It  seems  best  to  review  here  the  differential  diagnosis, 
at  the  exploratory  incision,  of  the  various  cystic  tumors. 

First,  a  cyst  containing  blood  without  a  papilloma  to  explain  the  hemorrhage 
has,  in  my  experience,  always  been  cancer.  A  cyst  containing  thick,  grumous 
material  has  always  been  cancer  (Fig.  518).  Tliis  material  is  due  to  broken-down 
epithelial  cells. 

The  possible  benign  cysts  of  the  breast  are  as  follows: 

The  galactocele  (Fig.  440)  has  a  thin,  smooth,  distinct  wall  containing  milk, 
and  is  surrounded  by  lactating  breast.  The  circumscribed  chronic  abscess  (Fig. 
461) — a  rare  lesion  in  the  lactating  breast  (page  196) — has  a  tliick  wall  lined  by 
vascular  granulation  tissue  and  contains  purulent  material.     This  cyst  will  be  most 


Fig.   517. — Cancer    Ctst;    Clinical    Picture 
Doubtful. 
Photograph  of  patient  from  Halsted's  clinic. 


CARCINOMA. 


247 


difficult  to  recognize  from  the  cancer  cyst  in  the  lactating  breast.  The  walls  look 
very  much  alike,  but  the  contents  of  the  cancer  cyst  is  thicker  and  more  granular. 
The  simple  cyst  has  a  smooth  wall  and  thin,  clear  or  cloudy,  serous  contents 
(Figs.  458  and  459).  I  have  never  observed  it  to  be  hemorrhagic.  The  cyst  con- 
taining a  benign  papilloma  may  contain  blood  (Figs.  475  and  476).     This  can  be 


Fig.  518. — Cancer  Cyst;    Typical  Cancer  in  Wall  at  x;    Breast  Senile. 
Photograph  from  painting  by  Miss  Hayes.     The  cyst  contained  typical,  soft,  granular,  hemorrhagic  cancer  material 

(see  Fig.  519). 


distinguished,  however,  from  the  malignant  papillomatous  cyst  by  the  changed 
appearance  of  the  growth,  projecting  from  the  wall  (Figs.  494  and  495)  (page  234). 

A  careful  review  of  my  notes  and  the  specimens  of  cancer  cysts  demonstrates 
that  their  contents  have  been  either  bloody,  or  thick,  granular  material  (Fig.  519), 
that  the  wall  is  either  thicker  and  more  intimately  ad- 
herent to  the  surrounding  breast  tissue  than  the  benign 
cyst,  and  when,  in  a  few  instances,  the  wall  has  been 
found  thin,  a  definite  thickening  could  be  palpated  in 
some  part  of  it,  which  on  incision  had  the  appearance  of 
cancer. 

In  a  sarcomatous  cyst  (Fig.  520)  sent  to  me  by  Pan- 
coast  the  cyst  wall  was  lined  by  a  friable,  cellular  tissue 
which  would  at  once  exclude  a  benign  cyst. 

In  the  fifth  cancer  cyst  admitted  to  the  surgical 
clinic,  clinically  doubtful,  Halsted  made  the  correct  diagnosis  at  the  exploratory 
incision  from  its  bloody  contents  and  from  a  palpable  tumor  in  the  smooth  wall 
of  the  cyst.  The  complete  operation  was  immediately  performed.  The  axillary 
glands  showed  metastasis.  This  patient  has  remained  well  for  the  two  years  and 
six  months  which  we  were  able  to  follow  her  after  the  operation. 


Fig.     519. —See     Fig.      518. 
Patient  of  Finney. 


248 


DISEASES    OF    THE    FEMALE    BREAST. 


The  Other  chnically  doubtful  cancer  cysts  were  received  in  the  laboratory  from 
outside  sources. 

I  have  recently  observed  two  simple  cysts  in  girls  under  twenty.  Both  followed 
traumatism.  In  one  the  fluid  was  slightly  browm,  but  not  definitely  hemorrhagic; 
in  both  remains  of  an  epithelial  lining  could  be  made  out. 

A  lymphatic  cyst,  or  a  cyst  due  to  a  tubercular  abscess,  similar  to  those  observed 


'P72^.y7^  ^ 


Fig.  520. — Sarcomatous  Cyst  of  Breast. 
Photograph  from  fresh  tissue,  section  through  cyst   and  breast;   both  halves  of   cyst   shown.     Note  distinct 
cyst  wall  lined  by  friable  granular  tissue.       Microscopic  examination  of  wall — perithelial  angiosarcoma.     Female, 
aged  fifty,   tumor  five  and   a  half  months;    chnically  benign;    excision  of    breast    only.      Patient  of    Pancoast. 
(Schapiro.) 

in  the  thigh,  is  possible.  I  have,  however,  never  observed  such  a  case,  nor  do  I 
find  anv  in  the  literature.  The  hydatid  cyst  and  the  benign  and  malignant  der- 
moids have  been  discussed. 


Sarcoma  of  the  Breast. 
Although  the  breast  is  rich  in  stroma,  malignant  connective-tissue  tumors  are 
rare.     Among  505  mahgnant  tumors  recorded  in  the  laboratory,  eighteen   (3.3 


SARCOMA. 


249 


Fig.  521. — Sarcoma  in  Huge  Intracanalicular  Myxoma. 
Photograph  of  patient.    (Courtesy  of  Lihenthal,  of  New  York.) 


per  cent.)  can  be  looked  upon  as  true  sarcomata.  As  half  of  these  were  obtained 
from  outside  sources,  the  percentage  of  cases  admitted  to  the  surgical  clinic  is  about 
one.  On  the  other  hand,  the  benign  fibroepithelial  tumors  are  the  most  common 
lesions.  Among  333  benign  lesions  of  the  breast,  fifty-four,  or  27  per  cent.,  were 
intracanalicular  myxomata, 
and  twenty-eight,  or  12  per 
cent.,  adenofibromata. 

Some  pathologists  might 
classify  with  sarcoma  the 
eleven  cases  which  I  have 
described  as  medullary  car- 
cinoma resembling  sarcoma. 
These  tumors  were  very  cellu- 
lar and  had  a  distinct  stroma. 
Clinically  they  were  all  malig- 
nant and  of  rapid  growth, 
all  showed  metastasis  to  the 
axilla,  none  was  cured. 

Classification.  —  Among 
the  eighteen  cases  of  sarcoma 

which  I  have  studied,  the  following  distinct  types  may  be  recognized :  the  sarcoma 
arising  in  the  intracanalicular  myxoma,  the  primary  sarcoma  of  the  stroma  of  the 
breast  (non-indigenous  sarcoma),  and  the  metastatic  sarcoma. 

Sarcoma  in  Intracanalicular  Myxoma. — During 
the  same  period  I  have  observed  fifty-four  examples  of 
the  benign  and  seven  (10  per  cent.)  of  the  malignant 
form  of  this  fibroepithelial  tumor. 

With  one  exception  the  malignant  tumor  has  only  been 
found  in  the  large  intracanalicular  myxoma  involving  half 
or  the  entire  breast. 

Of  eighteen  cases  in  which  half  or  the  entire  breast 
has  been  occupied  by  this  intracanalicular  myxoma,  six, 
or  33  per  cent.,  have  shown  areas  of  sarcoma.  For  this 
reason  every  large  intracanalicular  myxoma  should  be 
regarded  as  suspicious  and  removed  with  an  area  of  skin, 
a  wider  area  of  subcutaneous  fat,  and  the  entire  major 
pectoral  muscle.  It  is  not  necessary  to  remove  the 
axillary  glands.  All  cases  so  treated  have  been  cured, 
while  in  two  of  the  earlier  tumors  in  which  only  the 
breast  was  removed  there  was  rapid  local  recurrence  in  the  muscle  and  death  from 
pleural  metastasis. 

The  patients,  when  the  tumor  has  been  malignant,  have  been  between  forty 
and  fifty  years  of  age,  and  the  tumors  of  from  two  to  eight  years'  duration,  with  a 


Fig.  522. — Sarcoma  in    Bi- 
lateral   Huge    Intra- 
canalicular Myxoma. 
Patient,     aged     forty-two, 
tumor  of  right  breast  twenty- 
five  years;  small  and  no  growth 
for  fifteen  years;  tumor  of  left 
breast  three  months.     Com- 
plete excision  of  both  breasts 
by    Johnson,    of     Frederick, 
Md. 


250 


DISEASES    OF   THE    FEMALE   BREAST. 


history  of  recent  rapid  growth.     In  addition,  in  the  majority  the  skin  has  been  red 
and  adherent — chnically  mahgnant. 

The  large  intracanahcular  myxoma  can  be  recognized  by  its  distinct  lobulation 
(Figs.  521  and  522).  It  may  be  bilateral,  but  its  lobulation  distinguishes  it  from 
diffuse  hypertrophy.     In  the  large  tumors  exploratory  incision  is  never  necessary. 

In  my  only  example  of  a  smaller  intracanahcular  myxoma  which  has  become 
sarcoma, — the  patient  was  forty-six,  the  tumor  of  two  years'  duration, — it  occupied 
the  entire  upper  and  outer  quadrant  and  was  clinically  malignant,  because  palpa- 
tion made  out  infiltration  of  the  breast  outside  the  circumscribed  mass.  This 
patient  was  cured  after  complete  operation. 

The  small  intracanahcular  myxomata  are  rarely  observed  in  the  breasts  of  women 
over  thirty.  They  can  be  recognized,  however,  at  the  exploratory  incision.  They 
do  not  differ  from  the  tumor  in  younger  women 
(page  216). 

The  malignant  intracanahcular  myxoma  (Fig. 
523)  shows  in  places  the  characteristic  lobulations 
of  the  benign  tumor;  in  other  areas,  the  myxo- 
matous-cellular  picture  of  a  myxosarcoma.    Under 


KP'!SS"'^^W??!¥SP5n^?!P^5SS^W'q[W5SS 


Fig.  523. — Gross  Appearance  of  Sarcoma  in  Intracanalicular 
Myxoma. 
Photograph  section  through  breast,  alcohol  specimen.  Patient 
aged  forty-six,  tumor  two  years;  excision  of  breast  only;  local  re- 
currence in  muscle  and  pleura  two  months  after  operation;  death  a 
few  months  later. 


Fig.  524. — Photomicrograph 
(Wright)  of  Intracanalicular 
Myxoma  and  Sarcoma. 

Tissues  from  Johnson's  case  (see  Fig. 
522). 


the  microscope  we  can  recognize,  as  a  rule,  in  some  places,  the  remains  of  the  intra- 
canalicular myxoma  (Fig.  524) ;  in  other  areas,  spindle-cell  and  round-cell  sarcoma 
(Fig.  525).     In  one  of  my  cases  cartilage  and  giant-cells  were  present. 

Primary  Non-indigenous  Sarcoma. — Two  have  occurred  as  cysts  in  women 
aged  thirty-seven  and  fifty,  both  clinically  doubtful.  These  tumors  could  be 
recognized  by  the  soft,  friable  tissue  lining  the  wall  of  the  cyst;  in  one  the  contents 
was  hemorrhagic. 

The  solid  tumors  have  all  been  clinically  malignant  and  the  complete  operation 
for  carcinoma  performed  without  an  exploratory  incision.     None  have  been  cured. 

One  was  a  perithelial  angiosarcoma  in  a  woman  aged  fifty-five,  with  a  rapidly 
growing  tumor  of  two  months'  duration;   the  diagnosis  of  a  malignant  tumor  was 


DISEASE    OF   THE   AREOLA   AND    NIPPLE.  251 

based  upon  the  marked  edema  of  the  subcutaneous  fat.  Two  were  rapidly  growing 
fibro-spindle-cell  sarcomata  of  from  two  to  nine  months'  duration  in  women  over 
seventy;  both  chnically  mahgnant  on  account  of  the  infiltration  of  the  surrounding 
skin. 

The  non-indigenous  sarcoma,  on  account  of  its  rapid  growth,  will  resemble 
clinically  the  medullary  carcinoma,  and  the  same  complete  operation  should  be 
performed.  So  far,  the  prognosis  has  been  hopeless.  Should  these  tumors  be 
seen  early,  when  clinically  doubtful,  their  cellular  nature  will  undoubtedly  be 
easily  recognized  at  the  exploratory  incision. 

Metastatic  Sarcoma. — Three  cases  were  observed,  all  in  women  under  twenty; 
multiple  tumors,  of  rapid  growth  in  one  or  both  breasts.  The  primary  growth 
was  in  the  tonsil  in  one 
case,  in  the  ovary  in 
two  cases.  When  the 
primary  lesion  had 
given  no  evidence  of 
its  presence,  the  diag- 
nosis was  not  made 
until  one  of  the  tumors 
had  been  explored. 


'^ 


DISEASE    OF    THE 

AREOLA  AND  NIPPLE.  •    i^-:.:  ,J^>v-t>::^.  V'^-:'  '^^^^-..i  '. ;  .tl'iv*'*-'^     '    "•  r.' >^^^1 

Primary  lesions  of  "'^<''*i.>  ^^^^ '''f>t^'':-V''•.^-^'-■'' ''-•  ^^•«^-' ''^^'5^^^  .     "> 

the    nipple,    skin,    of  .^•.V--.-"';  \''\;..v '-;'.-,":V'\"-'V  '!;V^''^/^  >-'^^        ,►,;  . »  '    -J 

the  areola,   and    over  ■" "  •  i"  ,  :• '  ^V     iv'^v^V"  >;'^V;V  ;i^^^^-V 
the   breast    are    com- 

FiG.  525. — Photomicroghaph  (Wright)  of  Pure  Sarcomatous  Akea  from 

paratively  infrequent.  Same  breast  as  Fig.  524. 

The  two  most  com- 
mon are  congenital  depression  and  infections  of  the  nipple  during  lactation.  Ab- 
sence of  the  nipple  is  always  congenital,  bilateral,  with  few  exceptions;  in  some 
cases  the  breast  is  fully  developed.  Women  with  congenital  depressions  of  the 
nipple  may  be  unable  to  nurse  their  children;  if  nursing  is  attempted,  injury  and 
infection  of  the  nipple  are  more  common.  Unusual  care  should  be  exercised  in 
these  cases.  Some  authorities  on  obstetrics  advocate  in  cases  of  depressed 
nipple  a  treatment  during  the  pregnant  stage  which  consists  of  an  attempt 
to  overcome  the  depression  by  pulling  the  nipple  forward  or  covering  it  with 
a  cup.  During  lactation  extreme  care  in  cleanliness  of  the  nipple  and  mouth 
of  the  child  usually  prevents  the  infection  of  the  nipple.  The  first  lesion 
is  a  traumatic  abrasion  of  the  epidermis.  If  this  is  untreated,  fissures  form, 
then  ulcers,  and  later  a  fungus  due  to  exuberant  granulation  tissue.  At  any 
time  a  mastitis  is  possible  from   an  infection  along    the   lymphatics   that   come 


252  DISEASES    OF   THE   FEMALE   BREAST. 

from  the  lacteal  ducts.  In  the  treatment  cleanliness  is  of  the  first  importance; 
second,  protection  of  the  nipple,  during  nursing,  with  a  shield.  In  advanced  cases 
nursing  will  have  to  be  discontinued.  In  the  simple  abrasion  and  fissure  mild 
antisepsis  with  a  dressing  of  dry  powder  after  each  nursing  is  sufficient.  In  the 
ulcer  and  fungous  stage  the  lesion  should  be  disinfected  with  pure  carbolic  acid 
followed  by  alcohol  or  nitrate  of  silver. 

Paget's  Disease. — In  1874  Paget^  described  a  chronic  eczema  of  the  nipple 
observed  in  women  between  forty  and  sixty,  which  was  usually  associated  with 
ulceration  of  the  nipple.  In  every  one  of  his  cases  a  tumor  of  the  breast  developed. 
It  was  situated  beneath  or  not  far  from  the  nipple,  but  there  was  always  a  zone  of 
apparently  healthy  tissue  between.  Paget  viewed  the  lesion  of  the  nipple  as  pri- 
mary, and  although  he  had  never  observed  such  a  case,  he  was  inchned  to  the  opin- 


'  -^ 


Fig.  526. — Small,  Infiltrating  Scihrhus  to  Left;    Direct  Infiltration  of  Carcinoma  Through  Breast 
TO  Nipple  with  Destruction  of  Nipple  by  a  Carcinomatous  Ulcerating  Process. 
Question  as  to   Paget's  disease.     Photograph   from  painting  of  fresh    section   through   nipple  and   breast. 
Patient  aged  fifty-five,  eczema  and  ulceration  of  nipple  two  and  a  half  years;  tumor  noticed  but  five  months. 
Complete  operation;  metastasis  to  axilla.     Recent  case.     Patient  of  Pancoast. 

ion  that  in  some  instances  the  area  of  eczema  might  heal  without  the  development 
of  a  carcinoma  in  the  breast.  Since  then  the  literature  on  this  subject  has  been 
scanty,  as  observations  of  this  kind  are  unique.  Ehrhardt,^  in  reporting  one  obser- 
vation, considered  that  the  eczema  of  the  nipple  which  had  been  present  two  years 
before  the  tumor  of  the  breast  had  been  observed  was  the  primary  lesion.  In  the 
most  recent  communication  by  Schambacher^  an  opposite  view  is  maintained; 
that  is,  that  the  tumor  of  the  breast  is  the  primary  lesion,  and  the  changes  in  the 
skin  of  the  nipple  and  areola  are  secondary,  due  to  the  infiltration  of  the  cancer  cells 
directly  upward  from  the  tumor,  or  by  metastasis  along  the  ducts  or  lymphatics. 
I  have  never  observed  a  case  of  cancer  of  the  breast  in  which  a  primary  epithelioma 
of  the  nipple  could  be  considered  the  origin  of  the  neoplasm.     I  have  observed  a 

1  Paget:    St.  Barth.  Hosp.  Rep.,  x,  87. 

^Ehrhardt:    Deutsche  Zeitschr.  f.  Chir.,  1900,  liv,  130. 

5  Schambacher:    Deutsche  Zeitschrift.  f.  Chir.,  1905,  Ixxx,  332. 


RESULT   AND    DURATION    OF    LIFE   IN   MALIGNANT   TUMORS.  253 

few  cases  clinically  answering  the  description  of  Paget's  disease,  but  a  pathologic 
investigation  led  to  the  same  conclusions  as  those  reached  by  Schambacher.  Fig. 
526  shows  a  section  through  the  nipple  and  breast  of  a  patient  of  Pancoast  which  was 
considered  clinically  an  example  of  Paget's  disease.  The  apparently  free  interval 
between  the  tumor  and  ulceration  of  the  nipple  described  by  Paget  is  well  marked. 

For  practical  purposes  I  should  advise  that  every  case  of  chronic  eczema  with 
ulceration  of  the  nipple  in  a  woman  at  the  cancer  age  be  treated  as  a  carcinoma, 
even  though  a  breast  tumor  cannot  be  palpated,  unless  the  appearance  of  the  ulcer 
or  the  presence  of  other  distinct  lesions  allows  a  positive  diagnosis  of  syphilis. 

Other  Lesions  of  the  Areola  or  Nipple. — These  are  best  described  by  Sheild.^ 
They  are  very  rare.  I  have  observed  one  pedimculated  papilloma  of  the  nipple 
similar  to  the  one  pictured  by  Sheild,  and  one  encapsulated  solid  adenoma.  Cysts 
of  the  glands  of  Montgomery  have  been  reported.  These  unique  tumors  are  not 
difficult  to  recognize.  Primary  and  secondary  syphilitic  lesions  of  the  nipple,  as  a 
rule,  present  no  difficulties  in  diagnosis.  Primary  benign  and  malignant  tumors 
of  the  skin  of  the  breast  are  unusual. 


STATISTICS  AS  TO  ULTIMATE  RESULT  AND  DURATION  OF  LIFE  IN 
MALIGNANT  TUMORS. 

Life  After  Operation.^ — Fifty-five  patients  are  living  from  three  to  fifteen  years 
after  operation.  The  average  number  of  years  since  the  operation  of  these  patients 
is  8.45.  Twenty-two  patients  died  of  old  age,  or  of  intercurrent  diseases  with  no 
evidence  of  a  return  of  the  cancer:  eight  of  these  within  three  years  .after  operation, 
sixteen  from  three  to  ten  years  after  operation. 

Among  213  complete  operations  in  which  a  period  of  from  three  to  fifteen  years 
has  passed,  recurrent  carcinoma,  not  in  the  region  of  the  wound,  has  taken  place 
and  caused  death  in  fifteen  patients.  These  late  recurrences  have  been  observed 
from  three  to  eight  years.  The  average  duration  of  life  has  been  6.9  years.  I  wish 
to  emphasize  the  fact  that  statistical  figures  seem  to  show  that  the  patient  who 
remains  free  from  evidence  of  carcinoma  after  operation  for  eight  years  may  be 
considered  permanently  cured.  Later  recurrences  have  been  recorded  in  the  liter- 
ature, but  may  be  looked  upon  as  exceptions. 

Local  Recurrence. — In  Halsted's  chnic,  after  the  complete  operation,  local 
recurrence  in  the  scar  of  the  chest,  axilla,  or  neck  is  comparatively  rare.  It  has 
taken  place  in  twenty-three  cases;   that  is,  in  about  10  per  cent. 

We  have  never  observed  local  recurrence  after  three  years,  and,  with  few  ex- 
ceptions, the  recurrence  has  taken  place  within  eighteen  months.  The  average 
duration  of  life  after  operation  on  patients  dying  with  local  recurrence  has  been  but 
2.26  years,  evidence  not  only  of  the  malignancy  of  the  tumor,  but  of  its  extensive 
local  infiltration  at  the  time  of  the  operation,  ^^liether  there  has  been  a  personal 
element  in  a  somewhat  restricted  operation  is  difficult  to  estimate,  but  I  frequently 

'  Sheild:    Loc.  cit. 


254  DISEASES    OF   THE    FEMALE    BREAST. 

find  in  the  operative  note  and  in  my  pathologic  descriptions  the  statement  that  a 
smaller  area  of  skin  than  usual  has  been  removed. 

Regionary  Recurrences. — Recurrences  outside  of  the  scar  of  the  operation, 
which  cannot  be  explained  by  any  restriction  in  the  complete  excision,  have  taken 
place  in  about  forty-one  cases,  or  about  20  per  cent.,  and  the  average  duration  of 
hfe  in  these  cases  is  2.16  years. 

Internal  Metastasis. — Fifty-seven  patients  have  died  between  a  few  months 
and  four  years  after  operation  with  definite  symptoms  of  internal  metastasis,  which 
have  always  been  present  within  three  years  after  operation. 

These  figures  are  of  great  interest.  Among  121  patients  who  developed  signs 
of  local,  regionary  recurrence  or  internal  metastasis  the  average  duration  of  life 
is  less  than  two  and  a  half  years,  the  longest  six  years,  the  shortest  three  months. 
Twenty-one  of  these  cases,  or  17  per  cent.,  lived  three  years  or  more  after  opera- 
tion. If  we  add  to  these  the  fifteen  who  died  of  regionary  recurrence  after  three 
years,  we  find  that  26  per  cent,  of  patients  who  ultimately  died  of  the  disease  lived 
more  than  three  years  following  operation ;  the  longest  period  of  apparent  freedom 
has  been  eight  years,  the  longest  duration  of  life  twelve  years. 

The  average  duration  of  life,  therefore,  of  patients  upon  whom  the  complete 
operation  for  cancer  has  been  performed  (and  not  cured)  is  about  four  and  a  half 
years. 

Inoperable  Cases. — In  fifty-five  patients  an  operation  was  attempted,  but 
abandoned  because  of  infiltration  of  the  disease  beyond  any  possible  complete  eradi- 
cation. The  average  duration  of  Hfe  in  this  group  is  about  1.4  years,  as  compared 
with  4.7  in  which  the  complete  operation  was  performed  without  a  permanent  cure. 
Complete  excision,  therefore,  if  possible,  prolongs  life. 

Inoperable;  No  Operation. — In  sixteen  cases  the  disease  had  reached  such  a 
stage  that  no  operation  was  performed.  The  duration  of  hfe  in  this  group,  after 
the  onset  of  the  disease,  was  3.2  years,  as  compared  with  2.2  years  in  inoperable 
cases  in  which  an  operation  was  attempted;  that  is,  an  incomplete  operation  not 
only  shortens  life  after  the  operation,  but  the  probable  period  of  life  from  the  onset 
of  the  disease. 

Notwithstanding  this  fact,  I  am  of  the  opinion  that  the  complete  operation  should 
be  attempted  if  there  is  any  shadow  of  hope,  and,  in  addition,  in  certain  cases  it 
seems  justifiable,  when  the  tumor  is  adherent  to  the  chest  wall,  to  resect  ribs  and 
sternum  at  the  primary  operation. 

This  more  extensive  operation  should  be  selected  for  those  forms  of  adenocar- 
cinoma and  medullary  carcinoma  in  which,  although  the  tumor  extends  locally 
and  involves  intercostal  muscles  and  the  chest  wall,  this  local  infiltration  is  appa- 
rently not  associated  with  internal  metastasis. 

Life  After  Onset  of  the  Disease. — It  is  interesting  to  study  the  complete  dura- 
tion of  life  from  the  onset  of  the  first  symptom  (tumor)  to  death  in  those  cases  in 
which  the  carcinoma  has  been  the  cause  of  death.  To  ascertain  this,  one  adds  the 
duration  of  the  tumor  before  operation  to  the  time  which  the  patient  lived  after 
operation. 


RESULT   AND    DURATION    OF    LIFE   IN   MALIGNANT   TUMORS.  255 

In  patients  who  have  died  with  metastasis  three  years  or  more  after  operation 
the  average  total  duration  of  Kfe  has  been  8.26  years,  as  compared  with  hfe  after 
operation  of  6.9  years;  that  is,  the  average  duration  of  the  tumor  before  operation 
was  1.36  years.  When  this  is  compared  to  the  average  duration  of  the  tumor  in 
.  patients  cured,  we  find  that  the  tumor  in  the  former  (not  cured)  has  been  present 
longer — by  about  three  months.  This  is  the  best  evidence  that  I  can  find  of  the 
importance  of  an  early  operation.  The  longest  duration  of  life  in  a  patient  who 
developed  metastasis  after  three  years  has  been  thirteen  years. 

When  we  study  the  total  duration  of  life  in  patients  who  developed  local  or 
regionary  recurrence  or  internal  metastasis  before  three  years  after  operation,  we 
find  that  it  is  less  than  four  years,  and  the  average  duration  of  the  tumor  is  again 
found  to  be  a  few  months  longer  than  in  the  patients  who  died  of  metastasis  which 
did  not  manifest  itself  until  after  three  years  following  operation. 

Again,  when  we  study  the  total  duration  of  life  in  the  cases  in  which  the  opera- 
tion was  abandoned  on  account  of  hopeless  infiltration,  we  find  that  it  is  less  than 
two  and  a  half  years,  and  the  average  duration  of  the  tumor  before  operation 
longer. 

These  figures  demonstrate  that  next  to  the  pathology  of  the  tumor,  the  duration 
of  the  disease,  before  its  operative  removal,  is  the  most  important  factor  in  the  prob- 
ability of  an  ultimate  cure. 

The  average  duration  of  life  of  a  cancer  of  the  breast  from  the  onset  of  the 
disease  to  death  is  but  3.77  years.  It  is  possible  for  cancer  of  the  breast  to  produce 
death  within  six  months,  but  this  is  unusual  (less  than  1  per  cent.).  Fifty-six  per 
cent,  died  within  three  years,  but  41  per  cent,  lived  from  three  to  eight  years;  12 
per  cent,  lived  from  five  to  eight  years,  and  3  per  cent,  from  eight  to  sixteen  years. 
The  few  observations  of  a  duration  of  life  longer  than  nine  years  are  of  the  so-called 
atrophic  scirrhous  variety. 

I  emphasize  these  figures  because  I  feel  that  the  profession  is  not  aware  of  the 
latency  or  slow  growth  in  the  large  percentage  of  cases  of  carcinoma  of  the  breast. 

Recurrent  Carcinoma  of  the  Breast. — Among  the  cases  of  recurrence  ob- 
served in  Halsted's  clinic  after  the  complete  operation,  second  operations  have  been 
performed  in  a  number  of  instances.  Not  a  single  case  has  been  permanently 
cured,  although  in  three  the  patients  remained  apparently  well  for  three  years. 

I  am  of  the  opinion  that  a  local  or  regionary  recurrence,  after  a  complete  opera- 
tion properly  performed,  is  evidence  of  a  wide-spread  dissemination  of  the  disease 
at  the  time  of  the  first  operation. 

Incomplete  Operations. — In  a  few  cases  in  the  surgical  clinic  the  tumor  or 
breast  only  has  been  removed,  and  later,  after  the  microscopic  diagnosis  of  cancer, 
with  few  exceptions  the  complete  operation  performed.  Among  these  cases  there 
is  but  a  single  cure,  although  in  the  majority  the  tumor  belonged  to  the  least  malig- 
nant form  of  cancer.     This  I  have  discussed  under  Adenocarcinoma. 

During  the  same  period  forty-eight  patients  were  admitted  to  the  clinic,  or  tis- 
sues were  received  in  the  laboratory,  of  recurrent  carcinoma  after  an  incomplete 


256  DISEASES    OF   THE   FEMALE    BREAST. 

operation  performed  elsewhere.  In  some  the  tumor  only  was  removed;  in  others, 
the  breast;  in  a  very  few  a  partial  axillary  operation  was  performed.  In  only  six- 
teen (25  per  cent.)  was  a  complete  removal  of  the  recurrent  tumor  possible.  Among 
these  cases  there  are  but  two  that  were  permanently  cured :  a  comedo  and  a  colloid 
adenocarcinoma. 

The  evidence  of  my  observation  demonstrates  that  in  no  form  of  carcinoma  is 
an  incomplete  operation  justifiable. 


OPERATIVE  TECHNIC. 

The  various  operations  may  be  divided  into:  (1)  Incision  and  drainage  of  an 
abscess;  (2)  exploratory  for  diagnosis;  (3)  excision  of  single  or  multiple  tumors; 
(4)  excision  of  breast;  (5)  the  complete  operation  for  carcinoma;  (6)  the  modified 
operation  for  sarcoma  arising  in  a  large  intracanalicular  myxoma. 

Preparations  for  Operation. — With  the  exception  of  an  abscess  secondary  to 
lactation  mastitis,  all  other  patients  suffering  with  breast  lesions  should  be  prepared 
for  narcosis  and  the  complete  operation  for  cancer. 

When  the  tumor  is  clinically  malignant,  the  patient  should  be  narcotized  before 
the  operation  is  begun.  When  the  tumor  is  clinically  doubtful  and  the  age  of  the 
patient  and  palpation  of  the  tumor  favor  a  benign  lesion,  the  exploratory  incision 
may  be  done  under  local  cocain  anesthesia.  If  the  evidence  favors  the  probability 
of  a  malignant  tumor,  ether  should  be  given. 

The  axilla  should  always  be  shaved.  When  the  patient's  general  condition  is 
not  good  and  the  chances  are  that  the  complete  operation  will  have  to  be  performed, 
it  shortens  the  anesthetic  time  to  prepare  the  skin  before  ether  is  given. 

1.  Incision  and  Drainage  of  Abscess. — If  possible,  the  incision  should  be 
made  below  a  horizontal  plane  through  the  nipple.  As  a  rule,  this  can  be  performed 
under  cocain  anesthesia.  In  late  cases  the  pus  may  be  encountered  the  moment 
the  skin  is  divided.  In  earlier  cases  (the  best  time  to  operate)  one  divides  skin  and 
subcutaneous  fat,  exposing  the  breast  tissue.  The  presence  of  the  inflammatory 
focus  is  indicated  by  edema  and  infiltration  of  the  breast  tissue.  Now  and  then, 
before  incising  the  breast,  an  aspirator  should  be  employed  to  locate  the  pus  cavity. 
Before  incising  the  breast  it  should  be  infiltrated  with  cocain  solution.  After  open- 
ing the  abscess  cavity  it  afi^ords  better  drainage  to  excise  a  piece  of  breast  tissue.  In 
the  majority  of  early  cases  this  is  sufficient.  In  very  acute  cases,  in  which  there  is 
considerable  infiltration  beyond  the  pus  cavity,  it  is  safer  to  divide  the  posterior 
wall  of  breast  tissue  and  expose  the  space  between  the  breast  and  pectoral  fascia. 
The  gauze  drainage  is  then  placed  through  the  abscess  into  this  space.  This  pro- 
cedure prevents  the  formation  of  a  submammary  abscess,  which  not  infrequently 
is  observed  secondarily  to  the  simple  anterior  incision.  If  the  abscesses  are  multiple, 
each  should  receive  similar  treatment.  In  chronic  pyogenic  abscesses  the  wall  com- 
posed of  granulation  tissue  and  a  base  of  fibrous  tissue  should  be  excised.  It  is 
very  easy  to  demonstrate  non-infected  lactating  breast  tissue.     Both  in  acute  and 


OPERATIVE   TECHNIC.  257 

chronic  infections  the  inflamed  tissue  when  incised  does  not  weep  milk;   the  non- 
inflamed  tissue  does. 

2.  Exploratory  Incision  for  Diagnosis. — The  incision  shovild  be  made 
directly  over  the  tumor,  through  the  skin  and  subcutaneous  fat;  carefully  clamp  all 
bleeding  points  and  inspect  the  tissue  as  it  is  cut.  Quite  frequently  a  cancer  can 
be  recognized  by  the  point  of  the  knife  before  it  is  seen.  When  the  diagnosis  of 
malignant  tumor  has  been  made,  the  wound  is  swabbed  with  pure  carbolic  acid  or 
cauterized  with  Paquelin  and  closed.  Now  the  complete  operation  is  performed 
just  as  if  an  exploratory  incision  had  not  been  made. 

If  the  exposed  tumor  is  benign,  it  should  be  removed.  In  doing  this  one  has  an 
opportunity  to  inspect  the  appearances  of  the  surrounding  breast  tissue. 

3.  Excision  of  Tumor. — Whether  cystic  or  solid,  it  is  better  to  remove  the 
tumor  with  a  small  zone  of  breast  tissue.  In  removing  the  cyst,  which  of  course 
has  been  opened  for  diagnostic  purposes,  place  the  finger  of  the  left  hand  within 
the  cyst  and  clamp  the  edge  of  the  cyst  wall;  this  w^ill  facilitate  the  dissection. 
Always  carry  the  excision  through  to  the  pectoral  fascia.  To  close  the  wound 
approximate  the  breast  tissue  with  continuous  catgut  accurately  and  close  the  skin 
separately.     Drainage  is  not  indicated. 

Breast  tumors  can  readily  be  removed  under  cocain  anesthesia.  It  will  be 
necessary  to  infiltrate  the  breast  tissue  as  well  as  the  skin  before  making  the  incision. 

Multiple  Tumors. — I  have  always  removed  multiple  tumors  through  a  separate 
incision  for  each  tumor.  However,  Warren's  procedure^  appeals  to  me  as  having 
certain  advantages  for  the  excision  of  multiple  cysts  in  older  women.  At  the  present 
time  I  am  not  prepared  to  recommend  it  for  the  excision  of  a  single  tumor.  The  skin 
incision  is  carried  through  the  subcutaneous  fat  until  the  pectoral  fascia  and  muscle 
are  exposed  along  their  lower  border.  The  mammary  gland  is  separated  from 
the  pectoral  fascia  and  reflected  against  the  upper  portion  of  the  chest.  This 
exposes  the  posterior  surface  of  the  mammary  gland.  The  cysts  can  be  seen  or 
felt  and  are  removed  by  a  wedge-shaped  excision.  The  defect  in  the  breast  tissue 
is  closed  in  a  way  similar  to  that  described  after  the  excision  of  a  single  tumor, 
except  that  the  anterior  sutures  are  made  first.  The  breast  is  then  replaced  and 
sutured  to  the  pectoral  muscle  and  the  skin  incision  closed. 

I  have  used  this  method  only  once  in  the  removal  of  a  medium-sized  adeno- 
fibroma  situated  in  the  center  of  the  left  breast  of  a  girl  aged  sixteen.  The  pro- 
cedure requires  anesthesia.  The  incision  must  be  longer.  In  this  case  there  was 
a  resultant  keloid  which  required  secondary  operations.  For  the  removal  of  a 
single  tumor  I  am  of  the  opinion  that  the  method  described  here  will  be  found  to  be 
simpler  and,  on  the  whole,  better  than  the  plastic  resection  of  Warren. 

For  multiple  cystic  tumors  in  the  breasts  of  older  women  Warren's  operation 
meets  the  indications  in  a  very  satisfactory  way  and  is  less  mutilating  than  the  com- 
plete excision  of  the  breast.  One,  however,  must  be  quite  sure  that  the  breast  con- 
tains none  of  those  areas  which  might  develop  later  into  carcinoma. 

'  Warren:    Loc.  cit. 

VOL.  II — 17 


258  DISEASES  OF  THE  FEMALE  BREAST. 

4.  Excision  of  the  Breast. — When  the  exploratory  incision  into  the  tumor 
demonstrates  a  cyst  with  a  benign  papillomatous  growth,  or  an  area  of  senile  paren- 
chymatous hypertrophy  in  which  adenocystic  changes  are  marked,  the  entire  breast 
should  be  removed.  In  the  latter  instance,  it  is  my  opinion  that  both  breasts  should 
be  removed.  In  removing  the  breast  there  is  no  advantage  in  preserving  the  nipple. 
The  nipple  should  be  situated  in  the  center  of  a  small  elliptical  area  of  skin  which 
is  removed  with  the  breast.  The  direction  of  the  skin  incision  including  this  area 
should  be  an  oblique  line  from  the  sternal  edge  of  the  lower  and  inner  quadrant  to 
the  axillary  border  of  the  pectoral  muscle.  These  skin  flaps  are  dissected  with  the 
subcutaneous  fat  from  the  breast.  The  upper  flap  is  dissected  until  the  pectoral 
muscle  is  exposed  above  the  breast.  Then  the  breast  with  the  pectoral  fascia  is 
dissected  from  the  pectoral  muscle  from  above  downward  and  from  the  axillary 
border  toward  the  sternum.  One  will  always  find  a  projection  of  the  breast  tissue 
passing  into  the  axillary  fat  below  the  border  of  the  pectoral  muscle.  This  should 
be  removed  with  some  surrounding  fat.  A  few  vessels  will  be  exposed  here.  In 
separating  the  breast  from  its  sternal  border  one  encounters  the  perforating  branches 
of  the  internal  mammary  artery.  If  the  breast  and  the  pectoral  fascia  are  separated 
by  blunt  dissection  and  the  breast  lifted  and  drawn  downward  and  outward,  these 
vessels  are  easily  exposed  and  can  be  clamped  before  they  are  cut.  In  this  dissec- 
tion, as  one  leaves  the  subcutaneous  fat  with  the  skin  and  makes  the  incision  near 
the  breast  tissue,  the  operation  is  even  more  bloody  from  oozing  than  the  complete 
operation  for  cancer,  in  which  the  subcutaneous  fat  is  dissected  from  the  skin  and 
left  with  the  breast.  It  is  important  to  ligate  all  bleeding  points.  Even  with  careful 
hemostasis  there  is  usually  some  post-operative  oozing,  and  if  the  wound  is  closed 
without  drainage,  a  hematoma  is  not  infrequent.  For  this  reason  these  wounds 
should  be  drained.  I  prefer  one  or  two  pieces  of  rubber  tissue.  The  method  of 
closure  of  the  skin  is  unimportant.  The  operator  can  follow  his  usual  procedure. 
To  facilitate  the  escape  of  fluid  I  prefer,  in  addition  to  the  drainage,  the  interrupted 
skin  suture.  In  dressing  the  wound  considerable  loose  gauze  should  be  employed, 
with  which  the  axilla  is  well  padded,  and  this  gauze  should  be  held  in  place  with  a 
firm  bandage  about  the  chest,  including  the  shoulder  on  the  operative  side.  For 
at  least  five  days  the  forearm  should  be  carried  in  a  sling  and  the  arm  fixed  to  the 
side  of  the  body  to  prevent  use  of  the  pectoralis  major  muscle. 

When  the  breast  must  be  excised  for  tuberculosis  or  chronic  pyogenic  mastitis 
with  sinuses,  the  skin  incision  varies  to  include  the  sinuses,  and  the  deep  dissection 
should  be  made  beyond  the  infected  tissue. 

The  axillary  glands  are  removed  in  these  infected  cases  only  when  they  are  in- 
volved, and,  as  a  rule,  in  these  cases,  the  axillary  dissection  can  be  performed  without 
division  of  the  pectoral  muscle.  In  very  extensive  cases  of  tuberculosis  with  involve- 
ment of  the  pectoral  muscle  and  extensive  involvement  of  the  axillary  glands  the 
complete  operation  for  carcinoma  may  be  required  to  remove  all  the  infected  tissue. 
I  found  this  necessary  in  only  one  case. 

The  two  most  important  points  in  the  removal  of  the  breast  are  the  dissection. 


OPERATIVE   TECHNIC. 


259 


of  the  pectoral  fascia  with  the  breast,  which  is  done  simply  to  facilitate  the  operation, 
and  the  drainage  of  the  wound. 

5.  The  Complete  Operation  for  Cancer. — The  conception  of  this  now  ac- 
cepted procedure  should  be  credited  to  Halsted/  The  scheme  has  in  view  a  block 
dissection  of  the  breast  with  its  skin  covering,  a  wider  area  of  subcutaneous  fat, 
both  pectoral  muscles,  and  the  entire  axillary  contents  in  one  piece. 

Carcinoma,  as  stated  before,  is  unicentric  in  origin  and  extends  by  local  infiltra- 
tion along  lymphatic  vessels,  the  sheaths  of  blood-vessels,  and  the  fascia. 

We  have  no  means  of  ascertaining  in  what  direction  a  cancer  of  the  breast  has 
infiltrated.  The  area  removed  in  the  Halsted  operation  is  designed  to  block 
all  the  possible  directions  of  infiltration. 

Ste'ps  of  the  Operation. — Space  forbids  an  anatomic  discussion.  Before  per- 
forming this  operation  one  should  practise  it  on  a  cadaver  and  study  the  anatomy 
of  the  breast,  chest- wall  and  axilla, 
and  supraclavicular  fossa. 

The  operation  consists  of  the 
following  steps:  (1)  Position  of 
the  patient;  (2)  the  skin  and  sub- 
cutaneous fat  incision;  (3)  the 
division  of  the  pectoralis  major 
muscle;  (4)  the  division  of  the 
pectoralis  minor  muscle;  (5)  the 
axillary  dissection ;  (6)  the  supra- 
clavicular dissection;  (7)  the 
closure  of  the  wound. 

Position  of  Patient  (Fig.  527) . 
— As  the  operation  is  long,  the 
patient  shoidd  rest  upon  a  mat- 
tress. The  plain  of  the  axilla  is 
raised  by  a  bran  bag  beneath  the  scapula.  It  is  very  important  that  after  cleansing 
the  skin  the  back  of  the  patient  be  dried.  Pressure  necrosis  has  taken  place  from 
lack  of  this  precaution.  The  arm  is  held  by  an  assistant  at  a  right  angle  from  the 
body.  The  surgeon  must  constantly  watch  that  the  arm  is  never  overextended. 
The  danger  of  overextension  is  most  marked  after  the  division  of  the  muscles. 
Post-operative  monoplegia  is  due  to  overextension. 

Anesthesia. — Ether  by  the  drop  method  is  the  most  satisfactory.  The  narcosis 
after  the  skin  incision  should  be  unusually  light,  and  very  little  anesthetic  is  required. 
Toward  the  end  of  the  operation  when  the  skin  grafts  are  cut  the  narcosis  should 
be  deepened  for  a  few  minutes. 

Skin  hicision. — This  is  influenced  by  the  position  of  the  tumor  and  the  situation 
of  the  breast  on  the  chest  wall.  The  tumor  should  be  given  a  wide  area  and  the 
skin  over  the  breast  should  be  removed. 

'  Halsted:     Annals  of  Surgery,  Nov.,  1904. 


Fig.  527. — Position  of  Patient.  (Photograph  by  Schapiro.) 


260 


DISEASES    OF   THE    FEMALE    BREAST. 


The  first  incision  (Fig.  528)  begins  over  the  insertion  of  the  pectorahs  major  on 
the  arm,  and  curves  over  the  chest  above  the  breast  to  the  sternum,  and  extends  down 
between  sternum  and  breast;  if  possible,  the  level  of  this  incision  should  be  a  little 
below  the  border  of  the  pectoralis  major  over  the  axilla,  and  then  rise  again  as  it 
approaches  the  breast.  When  the  tumor  is  in  the  axillary  quadrant,  this  incision 
must  be  higher.  The  second  incision  extends  from  the  junction  of  the  middle  and 
inner  third  of  the  clavicle  toward  the  nipple,  and  divides  the  skin  above  the  first 
incision  into  two  infraclavicular  flaps — an  outer  and  an  inner.  These  two  flaps 
are  dissected,  leaving  the  subcutaneous  fat  with  the  muscle,  until  the  pectoralis  major 
muscle  is  exposed  to  its  clavicular  bundle  below  the  clavicle  and  to  the  sternum. 


Fig.  528. — Skin  Incision. 
Diagrammatic  sketch. 

Division  of  the  Pectoralis  Major. — The  tendinous  attachment  to  the  humerus 
is  isolated  and  divided  transversely  to  its  fibers  (Fig.  529).  I  prefer  to  insert  my 
finger  from  below  upward  and  to  slowly  follow  the  knife.  One  must  be  careful  of 
the  axillary  vein,  which  lies  just  below  the  muscle  at  this  point.  Grasping  this  por- 
tion of  the  major  pectoral  muscle,  it  is  separated  by  blunt  dissection  from  the  clavic- 
ular bundle  up  to  the  sternum.  In  making  this  blunt  dissection  one  meets  branches 
of  the  acromiothoracic  arteries  (Fig.  530),  which  should  be  ligated  close  to  the 
muscle.  The  proximal  ends  of  these  vessels  and  their  surrounding  fat  are  gently 
pushed  back  (Fig.  530).  The  pectoralis  major  muscle  and  the  breast  are  gently 
reflected  outward  and  downward.     The  left  hand  is  now  inserted  beneath  the 


OPERATIVE   TECHNIC. 


261 


pectoralis  major  muscle  and  the  latter  divided  from  its  sternal  attachments  from 
above  downward  (Fig.  530).  The  left  hand  is  used  to  gently  separate  the  muscle 
from  the  chest  wall  and  to  make  tension  during  the  division  of  the  tissue.  The 
perforating  branches  of  the  internal  mammary  artery  are  doubly  clamped  before  they 
are  divided.  When  this  division  of  the  muscle  is  complete,  the  proximal  ends  of 
these  arteries  are  ligated.     When  the  tumor  is  small  and  situated  in  the  outer 


JBl'eSbst 


Fig.  529. — Division  op  Pectoralis  Major  Tendon. 
Flaps  I  and  II  (See  Fig.  528);  BIV,  fat  to  the  upper  and  outer  quadrant  of  the  breast.    Photograph  of  operation  by 

Schapiro. 


hemisphere,  one  may  leave  a  stump  of  1  to  2  cm,  of  this  muscle  attached  to  the 
sternum.  If  the  tumor  is  an  infiltrating  one  and  situated  in  the  inner  hemisphere, 
the  muscle  must  be  divided  close  to  the  ribs  and  sternum.  I  am  quite  confident 
that  frequently  along  the  sternal  border  of  the  breast,  in  skin,  subcutaneous  fat,  and 
muscle,  sufficient  margin  of  uninvolved  tissues  is  not  included  in  the  excision  in  these 
cases  in  which  the  infiltrated  tumor  is  situated  in  the  inner  hemisphere  of  the  breast. 


262 


DISEASES    OF   THE    FE:\rALE    BREAST. 


In  making  this  more  extensive  dissection  one  will  find  more  difficulty  in  clamping 
the  perforating  branches  of  the  internal  mammary  artery. 

The  breast  and  major  pectoral  muscle  now  can  be  reflected  outward  and  down- 
ward against  the  side  of  the  body,  exposing  the  pectoralis  minor  muscle  and  axilla 
fFi^s.  581  and  532). 


Fig.  530. — Division    of    Pectoralis    Major    Muscle    from    Arm    to  a  Position-    Oxe-third  of   the   Way 

Along  the  Sternum. 
The  hand  mentioned  in  the  text  which  is  placed  beneath  the  muscle  is  not  shown.     Vessel  I,  branches  of  the 
acromiothoracic  vessels  and  fat  which  pass  between  the  two  pectoral  muscles  and  which  are  not  divided.     Clamp 
I  on  the  proximal  end  of  these  vessels  after  their  separation  from  the  pectoralis  major  muscle.     II  Clamp,  axil- 
lary edge  of  pectoralis  minor  muscle.     Photograph  of  operation  bj-  Schapiro. 


This  method  (known  as  Meyer's  modification)^  is  the  best  when  operating  upon 
the  right  side;  however,  on  the  left  side  it  is  more  convenient  to  begin  at  the  ster- 
num  and  di\'ide  the  muscle  in  the  opposite  direction. 

1  Jour.  Amer.  Med.  Assoc,  July  29,  1905. 


OPERATIVE    TECHXIC. 


263 


The  skin  incision  is  now  extender!  along  the  lower  and  inner  quadrant  and  out 
toward  the  axilla  along  the  lower  hemisphere  of  the  breast. 

Division  of  the  Pedoralis  Minor  (Figs.  531,  532,  533,  534). — One  always  finds, 
crossing  this  muscle  from  the  apex  of  the  axilla  to  the  tissue  of  the  axilla,  on  the 
lower  border  of  the  muscle,  a  branching  artery  and  accompanying  veins.  These 
vessels  are  surrounded  by  fat,  always  contain  lymphatic  vessels  and  tissue,  and  not 
infrequently  cancer  nodules. 


Fig.  531. — Division  of  Pectoralis  Minor  Muscle. 
Photograph  of  operation.     The  minor  pectoral  is  first  separated  from  its  sternal  origin.     Clamps  I  and  II  and 

Vessel  I  same  as  in  Fig.  530. 


I  prefer  not  to  divide  them,  but  by  gentle  l)lunt  dissection  to  push  these  vessels 
away  from  the  tendinous  attachment.  This  is  easily  done.  There  are  no  vascu- 
lar branches  entering  the  muscle.  Tlie  finger  is  then  introduced  from  above  down 
beneath  the  pectoral  minor  muscle  and  the  latter  divided  near  the  coracoid  process. 
As  a  rule,  one  vessel  is  encountered.  The  muscle  is  again  di\dded,  lea\'ing  a  stump 
attached  to  the  ribs  about  2  cm.  in  length.  In  making  this  di\asion,  place  the 
finger  between  the  muscle  and  the  rib,  pushing  the  loose  fat  and  delicate  veins  away 


264 


DISEASES    OF   THE    FEMALE    BREAST. 


from  the  muscle.  The  divided  muscle  usually  requires  three  to  four  clamps  to 
check  small  bleeding  points.  In  making  this  dissection,  one  must  use  great  care 
to  avoid  injury  of  a  delicate  plexus  of  veins  running  in  the  fascia  over  the  intercostal 
muscles.  The  division  of  the  pectoralis  minor  muscle  being  completed,  this  muscle 
and  the  vascular  tissue  passing  in  front  of  it  and  mentioned  above  now  fall  into  the 
axilla,  and  from  now  on  are  treated  as  axillary  contents  to  be  removed  in  one  piece. 
Axillary  Dissection  (Figs.  535,  536,  537,  538). — The  dissection  can  either  be 
begun  at  the  apex  of  the  axilla  (Fig.  536),  or  from  below,  beginning  at  a  point 
opposite  the  divided  pectoralis  major  tendon  (Fig.  529).     The  latter  is  less  difficult. 


Fig.  532. — Division  of  Pectoralis  Minor.     (Sketch.) 


The  only  object  of  the  former  is  based  on  the  theoretic  reason  of  blocking  the 
lymphatics.  One  will  find,  covering  the  brachial  plexus,  the  large  artery  and  vein, 
masses  of  fat  and  a  network  of  minute  vessels  in  a  definite  fascia.  If  this  is  nicked 
over  the  nerves,  it  can  be  torn  and  this  mass  of  tissue  brushed  with  a  piece  of 
gauze  down  over  the  vein.  Seldom  does  a  vessel  require  a  ligature.  One  quickly 
acquires  the  technic  of  this  manipulation.  Now  the  axillary  fat  is  grasped  and 
pulled  gently  from  the  vein.  This  puts  the  branches  under  slight  tension.  With 
an  artery  clamp  they  can  be  separated,  freed  from  fat,  doubly  clamped,  and  divided 
(see  Fig.  535).  When  artery  and  vein  lie  close  together,  they  should  be  separated 
and  each  clamped.     The  proximal  vessel  should  at  once  be  ligated :  it  is  not  a  safe 


OPERATIVE    TECHNIC. 


265 


Fig.  533. — Division   of  1'ectoralis  Minor. 

Photograph  from  dissection  of  cadaver.     This  illustrates  the  division  of  the  attachment  to  the  coracoid  process 

first.     X,  corresponds  to  Vessel  I  in  Fig.  531;  a  and  b,  to  clamps  I  and  II  in  Fig.  531.     c,  axillary  tissue. 


Fig.  534. — Division  of  Pectoralis  Minor  from  the  Ribs. 
Photograph  from  dissection  of  cadaver,     y,  stump  of  divided  tendon  of  pectoralis  minor;   x,  same  as  in  Fig.  533; 

clamps  also  identical  with  those  in  Fig.  533. 


266 


DISEASES    OF   THE    FE:\IALE    BREAST. 


procedure  to  leave  clamps  hanging  on  the  axillary  vein.  In  this  manner  one  pro- 
ceeds rapidly  along  the  vein  from  below  upward  or  from  above  downward. 
Except  at  the  position  of  the  acromiothoracic  axis,  all  the  vessels,  arteries,  and 
veins  run  downward  and  are  easily  separated,  clamped,  and  ligated.  The  only 
difficult  dissection  is  about  this  axis.  One  has  already  ligated  a  branch  or  two 
in  separating  the  pectoral  muscle  from  its  clavicular  bundle.  This  group  of  vessels 
is  surrounded  by  considerable  fat,  which  always  contains  lymphoid  tissue  and  not 
infrequently  metastatic  glands.  First,  the  vessels  should  be  ligated  close  to  the 
clavicular  border  of  the  greater  pectoral  muscle.  This  mass  should  be  turned 
down  over  the  artery.     As  a  rule,  the  numerous  distal  vessels  which  have  been 


Fig.  535. — Axillary  Dissection. 
Method  of  separating  branches  of  axillary  vein,  double  clamping  (a)  preliminary  to  division  and  ligation;   r, 
vein;  P.  m.,  pectoralis  minor,  which  has  been  divided;   x,  x,  x,  acromiothoracic  vessels  shown  in  Figs.  530,  53l' 
533,  and  534;    c,  c,  similar  to  clamps  I  and  II  in  previous  illustrations;   b,  clamp  on  tendon  of  pectoralis  minor  near 
coracoid  process.     Photograph  from  dissection  of  cadaver. 

ligated  are  branches  of  the  single  artery  given  off  by  the  axillary.  The  fat  should 
be  separated  from  the  larger  artery  and  this  branch  clamped  and  ligated.  Then 
the  mass  is  turned  down  over  the  vein  and  any  venous  branches  ligated.  I  have 
frequently  found  that  as  many  as  fifteen  clamps  and  ligatures  were  required  to 
complete  what  may  be  called  the  acromiothoracic  dis.section.  If  the  dissection  has 
proceeded  from  below,  when  one  reaches  the  apex  of  the  axilla  it  is  convenient  to 
grasp  the  now  free  mass  of  axillary  fat  and  pull  it  down  and  away  from  the  vein. 
This  facilitates  the  dissection  of  this  delicate  triangle.  If  one  begins  the  dissection 
from  the  apex,  it  requires  a  little  more  time  and  patience  to  get  all  of  the  fat  out 
of  this  triangle  without  injury  to  the  axillary  vein,  and  as  this  position  is  the  most 


OPERATIVE   TECHNIC. 


267 


serious  for  a  vein  injury,  I  would  recommend  that  the  operator  begin  the  dissection 
of  the  axilla  from  below,  until  considerable  experience  has  been  acquired.  The 
axillary  vessels  are  now  completely  freed  from  their  vascular  attachment  to  the 
axillary  contents.  One  now  proceeds  to  separate  the  axillary  tissue  from  the  chest 
wall.     This  is   most   conveniently   accomplished  by  grasping  the  axillary  tissue, 


Fig.  536. — Axillary  Dissection  from  Apex  of  Axill.\  Down. 
The  dissection  of  the  acromiothoracic  vessel.s  from  the  pectoralis  major  above  has  been  completed.     They 
are  in  the  mass  of  fat  above  the  exposed  axillary  vein.    Clamps  I  and  II,  same  as  in  previous  illustrations;   Clamp 
III,  similar  to  a  in  Fig.  5.35. 


pulling  it  from  the  chest  wall,  and  making  the  separation  with  the  gloved  hand  or 
a  piece  of  gauze.  Now  and  then  a  firm  strand  of  connective  tissue  or  a  small 
vessel  rec{uires  the  knife.  There  is  no  objection  to  l)lunt  dissection  along  the 
chest  wall.  This  should  be  carried  to  the  base  of  the  axilla.  There  is  now  a  mass 
of  axillary  tissue  which  has  deep  attachments  only  in  the  subscapular  fossa  (Fig. 
539),  that  part  of  the  axilla  situated  between  the  subscapular  muscle  and  the  chest. 


268 


DISEASES    OF   THE    FEMALE    BREAST. 


Following  the  same  plan  of  blunt  dissection  with  the  hand  or  gauze,  this  mass  of  fat 
is  separated  from  the  chest  on  one  side  and  the  subscapular  muscle  on  the  other. 
When  it  is  freed,  it  is  drawn  out.  Its  apex  is  situated  deep  behind  the  axillary 
vessels.  A  clamp  should  be  placed  as  high  up  as  possible  before  the  apex  is  severed 
and  the  mass  reflected  down  and  out  toward  the  base  of  the  axilla.  As  the  separa- 
tion is  carried  posteriorly  from  the  apex  down,  a  few  more  vessels  between  the 


J  \m 


Fig.  537. — Further  Dissection  Downward  Alonl:  the  Axillary  Vein. 
The  acromiothoracic  vessels  have  been  divided  from  the  artery  and  vein,  and  with  their  surrounding  fat  ai 
lymphatics  have  been  turned  down  toward  the  base  of   the  axilla  (Clamp  IV),  covering  clamps  I,  II,  and  III 
shown  in  Fig.  536.     Clamp  V  is  attached  to  the  tissue  removed  from  the  apex  of  the  axilla. 


scapular  muscles  and  the  chest  wall  require  clamping  and  ligature.  The  three 
difficult  places  in  the  axilla  for  a  complete  dissection  are :  the  area  about  the  acromio- 
thoracic vessels,  the  apex  of  the  axilla,  and  the  apex  of  the  subscapular  fossa. 

The  Co77ipletio}i  of  the  Operation  (Fig.  540). — The  axillary  tissue  is  turned  over 
against  muscle  and  breast  and  dissected  from  the  subscapular  teres  major  and 
latissimus  dorsi  muscle.  Large  vessels  pass  between  these  muscles;  the  dissection 
here  should  be  carefully  done  and  the  muscles  should  be  cleaned  of  fat  and  fascia. 


OPERATIVE   TECHNIC. 


269 


The  dissection  is  then  carried  to  the  skin  and  the  subcutaneous  fat  is  cleansed  from 
this  skin  which  was  situated  over  the  axilla.  In  separating  the  completely  dissected 
block  of  tissue  from  the  skin  which  covered  the  axilla  and  was  situated  to  the  outer 
side  of  the  breast,  one  is  governed  by  the  position  of  the  tumor.  If  the  disease  is 
situated  well  within  the  inner  hemisphere,  make  a  large  axillary  flap;  if  in  the 


Fig.  538. — Further  Dissection  Ai.on';;  the  Axillary  Vein. 

To  illustrate  the  separate  double  clamping  of  accompanying  large  venous  and  arterial  branches.     Clamp  VI  on 

venous  branch;   Clamp  VII  on  arterial  branch.     Photograph  from  operation. 


outer  hemisphere  or  in  the  axillary  border  of   the   breast,   the  size  of   the  axillary 
flap  must  be  reduced  to  give  the  disease  a  good  margin. 

The  Supraclavicular  Dissection. — When  this  is  indicated  by  the  inspection  of 
the  axillary  metastasis  (already  discussed),  the  skin  incision  already  made 
to  the  clavicle  is  extended  upward  until  it  meets  the  sternocleidomastoid 
muscle  at  the  position  a  little  above  the  omohyoid.  The  skin  and  subcutaneous 
fat  are  dissected  back  until  there  is  exposed  a  triangular  space  bounded   by  the 


270 


DISELASES    OF    THE    FEMALE    BREAST. 


Sternocleidomastoid  muscle,  the  clavicle,  and  the  base  of  the  outer  skin  flap  which 
crosses  the  cla\'icle  at  about  the  junction  of  the  middle  and  outer  third.  One  now 
makes  a  triangle  of  the  deeper  tissues,  cutting  the  fascia  and  stripping  it  back  and 
down  alono-  the  outer  border  of  the  sternomastoid,  and  then  along  the  clavicle. 
The  internal  jugular  vein  is  exposed  from  above  downward.  In  the  upper  portion 
the  omohyoid  belly  is  met  and  (Kvided,  one  portion  being  retracted  over  the  sterno- 
mastoid, the  other  outward.     These  make  good  retractors  and  limit  the  upward 


Fig.  539. — Dissection  of  Subscapular  Fossa. 
Clamp  VIII  is  attached  to  this  tissue,  which  hes  between  the  ches^t  wall  and  the  subscapular  muscle.     Photograph 

from  operation. 


extension  of  the  dissection.  All  the  tissue  is  freed  from  the  internal  jugular  vein 
down  to  the  clavicle.  Then  the  dissection  is  made  from  this  point  out  along  the 
clavicle.  One  quickly  encounters  the  external  jugular,  which  is  clamped,  cut,  and 
ligated.  This  triangular  piece  of  tissue,  the  apex  of  which  was  situated  between 
the  internal  jugular  and  subcla\ian,  is  reflected  outward  and  stripped  from  the 
muscles  forming  the  base  of  this  triangle.  Quite  a  few  veins  and  arteries  are  en- 
countered, but  they  are  easily  recognized  by  placing  tension  on  this  triangular  flap 
of  tissue.     The  dissection  is  carried  until  the  levator  scapuhe  muscle  is  reached. 


OPERATIVE   TECHXIC. 


271 


This  corresponds  to  the  base  of  the  already  reflected  outer  skin  flap.  The  base  of 
this  triangular  mass  of  tissue  is  now  divided,  better  from  above  downward.  It  is 
always  very  vascular. 

Closure  of  the  Wound. — For  that  portion  of  the  wound  in  which  contiguous 
skin  flaps  can  be  approximated  any  method  of  suture  may  be  employed.  The  open 
wound  is  reduced  in  size  by  a  purse-string  suture  of  silver  wire.  I  am  quite  confi- 
dent that  silver  is  the  suture  of  choice  here.  During  the  skin  suture  an  assistant 
should  be  cutting  grafts  from  the  opposite  thigh,  which  can  be  prepared  before 


Tufor^Hi    >n,l  <i~ 


/?i'l{l'^" 


Fig.  540. — Sketch  of  thp:  Completed  Dissection. 
There  only  remains  the  division  of  the  skin  of  the  axillary  flap. 

operation,  or  very  easily  during  the  latter  part  of  the  operation.  The  large  grafts 
are  spread  on  rubber  tissue,  raw  surface  up.  This  prevents  them  from  curling. 
They  are  placed  on  the  wound  and  the  rubber  tissue  gently  pulled  off.  In  the 
majority  of  cases  the  entire  defect  is  covered  and  the  graft  should  overlap  the  skin 
edge.  In  a  few  cases,  when  the  patients  are  very  fat  and  there  is  more  oozing  than 
usual,  one  should  leave  the  zone  of  raw  tissue  between  the  skin  ed^e  and  the  graft, 
otherwise  the  wound  secretion  will  collect  under  the  grafts,  preventing  organization. 
Drainage. — In  my  own  practice  I  do  not  drain  these  wounds.     If  one  is  very 


272 


DISEASES    OF   THE    FEMALE    BREAST. 


careful  in  hemostasis  it  is  unnecessary.  Quite  a  number  of  surgeons,  however, 
prefer  to  drain  the  axiha  through  a  stab  incision  made  in  the  base  of  the  axillary 
flap. 

Dressing. — The  raw  surface  on  the  thigh  is  covered  with  a  piece  of  protective 
smeared  with  sterilized  boric  vaselin  ointment,  and  this  protective  is  held  in  place 
by  adhesive  straps.  This  is  covered  with  a  roll  of  sterile  gauze  and  a  bandage. 
The  breast  wounds,  both  approximated  skin  and  skin  grafts,  are  covered  ■vv^th  sil- 
ver foil  and  paper,  and  this  in  turn  covered  with  loose  gauze.  The  most  important 
point  in  the  dressing  is  the  packing  of  the  axilla.  The  arm  should  be  placed  at  an 
angle  of  about  forty-five  degrees  to  the  body,  and  this  space  filled  with  gauze.  The 
bandage  should  include  the  arm  with  the  body.  The  padding  between  the  arm 
and  the  body  is  held  in  place  by  turns  over  both  shoulders,  taking  in  the  base  of  the 
packing  between  the  elbow  and  the  body.     If  the  neck  operation  has  been  done. 


Fig.  541. — Ultimate  Result  after  Bilateral  Operation. 
Eighteen  months  after  operation  on  right  side  and  six  months  after  operation  on  left  side.      (Ttds  patient  has  been 

permanently  cured.)     Halsted's  chnic. 


it  should  be  covered  with  loose  gauze  and  included  in  the  shoulder  bandage  with 
additional  turns  around  the  neck.  .  The  entire  dressing  should  be  fixed  with  crino- 
line or  plaster  bandage,  and  the  forearm  supported  by  a  sling.  The  dissection  of 
the  axillary  flap  fFig.  535)  and  its  proper  packing  with  external  gauze  to  preserve 
the  fornix,  and  the  fixation  of  the  arm  in  marked  abduction,  are  the  most  important 
measures  in  the  technic  of  the  operation  to  prevent  future  restricted  motion  of  the 
arm. 

In  some  cases  in  which  the  tumor  is  situated  in  the  axillary  quadrant  of  the 
breast  so  much  of  the  axillary  flap  must  be  sacrificed  to  give  the  tumor  a  wide  berth 
that  it  becomes  necessary  to  make  a  large  flap  of  what  is  left  of  the  axillary  flap  by  a 
transverse  incision  from  the  junction  of  the  axillary  flap  to  the  skin  at  the  lower 
and  outer  quadrant  posterior  over  the  chest  wall.  This  has  been  required  in  about 
4  per  cent,  of  the  cases. 


OPERATIVE   TECHNIC. 


273 


Plastic  Operations  on  Muscle  and  Skin. — In  the  experience  of  Halsted's  clinic 
the  functional  use  of  the  arm  after  operation  has  been  so  uniformly  good  (Figs.  541 
and  o42j  that  I  fail  to  see  the  justification  of  various  plastic  procedures.  Crile^ 
divides  and  later  sutures  the  pectoralis  minor  muscle.  This  procedure  was  also 
employed  a  number  of  years  ago  by  Halsted.  I  have  examined  these  cases  carefully, 
and  was  unable  to  demonstrate  any  improved  function.  I  agree  w^th  Halsted  that 
this  procedure  has  an  element  of  danger,  in  that  cancerous  tissue  might  be  left  in 
the  muscle.  The  same  arguments,  I  believe,  apply  against  the  plastic  method  on 
both  muscles,  advocated  by  Murphy.^  Even  granting  that  this  plastic  measure  does 
add  somewhat  to  the  future  function  of  the  arm,  I  believe  the  risks  of  an  incomplete 
dissection  of  the  axilla  too  great  to  justify  it.  A  number  of  surgeons  employ  some 
method  of  plastic  incisions  to  facilitate  the  complete  closure  of  the  skin  defect. 
There  are  no  objections  to  such  methods  if  the  area  of  skin  removed  with  the  breast 
is  not  reduced  in  size.  Warren's 
method^  impresses  me  as  one  of  the 
best.  I  have  had  no  experience 
with  any  of  these  modifications 
and  I  have  no  reason  to  regret 
skin  grafting,  which  appeals  to  me 
as  simpler  and  quicker,  Payr's* 
method  of  dislocating  the  opposite 
breast  does  not  appeal  to  me. 

Accidents  During  Operation. — 
If  the  dissection  is  performed  care- 
fully and  bloodlessly,  accidents 
should  not  happen.  Richard  R. 
Smith'  has  collected  the  injuries 
to  axillary  vessels  during  opera- 
tions for  carcinoma  of  the  breast. 
If  the  axillary  vein  is  torn,  lateral 

ligature  or  suture  is  not  at  all  difficult;  even  ligation  of  the  vein,  if  necessary, 
is  not  followed  by  any  bad  effects. 

After-treatment. — A  subcutaneous  infusion  of  salt  solution  can  be  given  under  the 
opposite  breast,  if  indicated,  before  the  dressing  is  applied.  This  is  seldom  neces- 
sary. When  the  patient  reaches  the  ward,  it  is  a  good  routine  plan  to  give  an 
enema  of  salt  solution  every  four  or  six  hours  for  twenty-four  hours.  Feeding  by 
mouth  can  be  begun  as  soon  as  the  post-operative  nausea  will  permit.  These  pa- 
tients are  usually  on  soft  diet  at  the  end  of  forty-eight  hours  and  ordinary  diet  on 
the  fourth  day.     The  patient's  head  and  shoulders  can  be  supported  by  pillows  as 

'  Crile:    Ohio  State  Med.  Jour.,  Oct.,  1905. 

^  Murphy:   "Surgery,  Gynecology,  and  Obstetrics,"  Jan.,  1906,  ii,  84. 
^  Warren:     Annals  of  Surgerj^  Dec,  1904. 
*Payr:    Deutsche  Zeitschr.  f.  Chir.,  1906,  Ixxxi,  361. 
^  Smith,  Richard  R.:    Annals  of  Surgery,  May,  1904. 
VOL.  n — 18 


Fig.  542. — Ultimate    Result    Tex  Years    After  Oper.\- 

TIOX. 

Healing  by  granulation;  no  skin-grafting.     Halsted's  clinic. 


274  DISEASES    OF   THE    FEMALE    BREAST. 

soon  as  nausea  has  ceased.  There  is  no  objection  to  their  sitting  up  in  bed  on  the 
next  day.  If  the  pulse  is  good,  the  patient  is  generally  able  to  be  up  in  a  chair  by 
the  fourth  day.  I  have  never  observed  an  embolism.  If  the  patient's  general 
condition  is  good,  I  have  never  seen  bad  effects  from  allowing  them  to  get  up  in  a 
chair  by  the  fourth  day.  One,  however,  should  vary  one's  treatment  as  indicated 
by  the  comfort  and  the  strength  of  the  patient.  In  the  majority  of  cases  the  wound 
does  not  require  dressing  for  ten  days.  The  stitches  are  then  removed,  and  now 
the  grafted  area,  if  there  be  any  islands  of  granulation  tissue,  requires  more  fre- 
quent dressing.  If  the  wound  is  dry  and  clean,  the  silver  foil  can  be  repeated. 
If  it  is  moist,  because  of  a  larger  area  of  granulation  tissue,  a  simple  dressing  of 
sterilized  boric  vaselin  meets  the  indications.  The  abraded  thigh  from  which  the 
grafts  have  been  taken  has  usually  healed  at  the  end  of  ten  days.  If  fat  has  been 
exposed  in  taking  the  graft,  healing  is  delayed.  The  arm  should  not  be  included 
in  the  dressing  after  the  second  week,  and  from  now  on  should  have  gentle  passive 
motion  and  massage,  and  the  patient  should  be  urged  to  use  it.  After  the  second 
week  the  patient  should  be  urged  to  attempt  to  raise  the  arm  to  the  complete  ele- 
vated position. 

The  Modified  Operation  for  Sarcoma. — In  the  tumors  involving  the  entire  breast, 
which  clinically  have  the  lobulation  and  elasticity  of  an  intracanalicular  myxoma,  a 
modified  operation  may  be  performed.  The  area  of  skin,  unless  the  tumor  be  adhe- 
rent, may  be  so  reduced  that  the  defect  can  be  closed  without  skin  grafting.  After 
the  skin  flaps  are  dissected  back,  a  wide  area  of  subcutaneous  fat,  including  the 
tumor  and  breast,  is  dissected  until  the  pectoral  muscle  is  reached.  This  muscle 
is  then  divided,  beginning  near  its  attachments  to  the  humerus  and  continuing  the 
separation  to  the  sternum.  The  division  of  the  muscle  need  not  be  as  near  the 
humerus,  or  the  separation  as  near  the  clavicle,  as  in  the  complete  operation  for 
carcinoma.  The  muscle  is  then  removed  from  its  sternal  attachments.  In  all 
other  forms  of  malignant  tumors  of  the  breast  the  complete  operation  for  carcinoma 
should  be  employed. 

The  Operative  Mortality. — After  operations  for  benign  lesions  of  the  breast  there 
have  been  no  deaths.  In  the  surgical  clinic  of  the  Johns  Hopkins  Hospital  464 
operations  have  been  performed  for  carcinoma,  including  operable,  inoperable, 
and  recurrent  tumors,  with  thirteen  deaths — a  mortality  of  2.8  per  cent.  The  cause 
of  death  was  as  follows :  One  on  the  table,  the  cause  for  which  could  not  be  ascer- 
tained; three  from  post-operative  pneumonia  between  the  fifteenth  and  thirty- 
second  days;  in  two  of  these  patients  the  tumor  was  inoperable  and  there  were 
metastases  to  the  lung  and  pleura;  secondary  hemorrhage  from  the  wound  in  one 
case  on  the  thirty-second  day — the  tumor  was  inoperable;  embolism  in  one  case 
on  the  eleventh  day;  secondary  infection,  five  cases  between  the  twelfth  and  eigh- 
teenth days ;  of  these,  the  tumor  was  inoperable  in  one ;  one  patient  with  an  inopera- 
ble tumor  succumbed  forty-eight  days  after  operation  from  general  carcinosis; 
another,  with  a  recurrent  tumor,  three  weeks  after  operation,  to  colitis. 

The  mortality  in  operable  cases  in  which  the  complete  operation  has  been  per- 


OPERATIVE   TECHNIC.  275 

formed  has  been  two  per  cent. — 269  cases  with  6  deaths.  The  mortality  is  higher 
when  the  supraclavicular  operation  is  performed — almost  3  per  cent. ;  while  when 
the  operation  has  been  limited  to  the  axillary  dissection,  the  mortality  is  less  than 
1  per  cent.  The  chief  danger  in  the  complete  operation  for  carcinoma  is  infection 
during  and  after  operation.  The  surgeon  should  wear  gloves,  and  the  mouth 
should  be  protected,  because  during  the  long  dissection  the  surgeon  may  breathe 
or  talk  into  the  wound  and  project  bits  of  infected  saliva.  As  far  as  could  be  as- 
certained, in  only  one  of  the  five  cases  of  infection  did  this  take  place  during  the 
operation;  the  others  were  undoubted  examples  of  secondary  infections  in  the  ward 
during  dressing  of  the  wound.  Two  of  these  occurred  in  patients  in  the  same 
ward  and  at  the  same  time;   in  this  ward  there  had  been  a  few  cases  of  erysipelas. 

During  the  last  seven  years,  among  121  complete  operations,  there  has  not  been 
a  single  infection  of  the  wound,  and  but  one  death ;  this  occurred  on  the  table,  and 
its  cause  could  not  be  ascertained.  During  the  same  time  there  has  been  but  a 
single  infection  among  twenty-one  inoperable  cases. 

Post-operative  Complications.— -With  the  exception  of  the  case  above  referred 
to  in  which  the  complication  caused  death,  other  complications  have  been,  as  a 
rule,  so  insignificant  that  exact  figures  as  to  their  possibility  have  not  been  accu- 
rately compiled.  The  following  have  been  noted.  Infection  of  the  wound — very 
unusual ;  total  sloughing  of  the  skin-graft  was  observed  in  only  a  few  cases  in  which 
the  wound  was  infected;  partial  sloughing  of  the  skin-graft — this  also  has  only 
been  observed  infrequently;  its  only  complication  is  a  slightly  prolonged  healing 
of  the  wound.  In  a  few  cases  of  very  extensive  carcinoma  in  which  the  skin  flaps 
were  dissected  extremely  long  sloughing  of  the  edges  has  been  observed.  The  com- 
parative percentage  of  pneumonia  and  bronchitis  has  been  unusually  small  as  com- 
pared with  those  following  laparotomies.  We  have  never  observed  phlebitis  of 
the  leg.  Monoplegia  of  the  arm  followed  in  four  cases — less  than  2  per  cent.  In 
every  instance,  I  am  confident,  it  was  due  to  overextension  of  the  arm.  In  the  last 
three  years  this  unfortunate  complication  has  not  occurred.  All  of  the  cases  made 
a  slow  but  permanent  recovery.  There  has  been  one  case  of  neuritis — a  very 
painful  and  tedious  post-operative  complication. 

If  anesthesia  is  properly  given  and  the  operation  is  performed  with  careful 
attention  to  technic  and  cleanliness,  the  complete  operation  for  malignant  tumor 
of  the  breast  should  have  a  low  mortality  and  insignificant  post-operative  complica- 
tions. 


CHAPTER  XXXII. 

OPERATIONS  UPON  THE  GALL-BLADDER,  BILE-DUCTS,  AND  LIVER. 

By  Albert  J.  Ochsnee,  M.D, 

HISTORY. 

The  gross  pathology  of  liver  abscess,  echinococcus  cyst,  dropsy  of  the  gall-blad- 
der, and  obstructive  jaundice,  together  with  the  essential  features  of  the  symptom- 
atology of  these  affections,  has  been  well  known  for  centuries.  It  is  therefore  not 
surprising  to  find  suggestions  as  to  the  possibility  of  operative  interference,  and  even 
attempts  at  the  operations  themselves,  being  made  long  before  the  introduction  of 
anesthesia  and  antisepsis  made  it  technically  possible  for  the  surgeon  to  undertake 
successfully  such  operative  procedures. 

In  accordance  with  the  surgery  of  their  time  we  find  the  older  surgeons,  from  the 
time  of  Hippocrates  until  the  modern  surgical  era,  confining  themselves  chiefly  to 
the  simple  incision  or  puncture  of  those  liver  or  gall-bladder  abscesses  which  already 
of  themselves  gave  indications  of  opening  on  the  surface.  Thus  Morgagni^  in  1761 
savs:  "It  does  not  escape  me,  however,  that  before  the  swelling  occupies  all  the 
muscles  which  lie  before  the  cyst,  causes  considerable  suppuration  on  all  sides,  and 
the  pus  forms  winding  sinuses  for  itself,  ....  the  case  must,  of  course,  turn 
out  more  successfully  for  those  who  open  by  incision  the  cyst  which  has  not  coalesced 
with  the  peritoneum."  In  spite  of  this  clear  conception  of  the  benefits  to  be  de- 
rived through  surgical  drainage,  IMorgagni  states  that  he  himself  prefers  to  wait 
"till  time  shall  confirm  its  advantages  and  remove  all  doubts,  dangers,  and  difficul- 
ties by  many  repeated  experiments." 

Jean  Louis  Petit,^  as  early  as  1733,  fully  described  the  operation  of  cholecystot- 
omy,  essentially  as  it  is  now  done,  and  actually  advocated  the  operation  as  a  de- 
liberate therapeutic  procedure.  In  support  of  his  views  Petit  quotes  four  cases, 
the  majority  operated  on  for  a  supposed  abscess.  Two  of  these  cases  died  and 
two  recovered,  one  of  them  with  a  fistula  through  which  a  calculus  was  removed  at  a 
later  date. 

Obviously,  the  technical  difficulties  of  such  an  operation  as  Petit  advocated  were 
too  great  to  be  successfully  overcome  by  the  surgery  of  this  period,  and  it  is  not  until 
after  the  introduction  of  anesthesia  that  we  find  the  operations  again  seriously  con- 
sidered. 

^  Morgagni,  Joannes  Baptista:  "De  Sedibus  et  Causis  morborum,"  etc.,  1761,  Bk.  iii.  Letter 
xxxvi,  Art.  52. 

^  Petit,  Jean  Louis:  Memoires  de  I'Acad.  roy.  de  Chir.,  1743,  i,  255.  (Paper  originally  read  irt 
1773.)    Maladies  Chirurgicales,  1790,  i,  282. 

276 


HISTORY.  277 

In  1859  Thudichum^  suggested  an  operation  for  the  extraction  of  these  foreign 
bodies  by  establishing  a  bihary  fistula  and  crushing  the  stone.  As  a  possible 
procedure,  he  proposed  to  open  the  abdomen,  seize  the  gall-bladder,  fasten  it  to 
the  abdominal  wall,  and,  after  adhesions  had  formed,  to  open  it. 

Although  the  earlier  literature  on  the  subject  shows,  it  is  true,  that  the  operation 
of  cholecystotomy  had  been  discussed  and  practised  before  Sims'  operation,  it  must, 
nevertheless,  be  conceded  that  to  him  is  due  the  credit  of  placing  it  on  a  new  basis 
as  a  deliberate  operation  in  the  surgery  of  the  abdomen. 

Sims^  performed  his  operation  April  18,  1878,  and  that  he  fully  comprehended 
the  essential  surgical  possibilities  not  only  of  cholelithiasis  but  also  of  liver  abscess 
and  hydatid  cyst  there  can  be  no  doubt.  He  expresses  as  his  conviction  that :  ''  The 
great  lesson  this  case  teaches  is  this:  In  dropsy  of  the  gall-bladder,  in  hydatid 
tumors  of  the  liver,  in  suspected  abscess  of  the  liver,  and  in  gall-stones  we  should 
not  wait  until  the  patient's  strength  is  exhausted,  or  till  the  blood  becomes  bile- 
poisoned,  producing  hemorrhages,  but  we  should  make  an  early  incision,  ascertain 
the  true  nature  of  the  disease,  and  then  carry  out  the  surgical  treatment  that  the 
necessities  of  the  case  demand." 

First  to  follow  the  lead  of  Sims  was  W.  W.  Keen,^  of  Philadelphia,  to  whom  is 
due  the  credit  of  the  first  cholecystotomy  performed  in  this  country. 

Lawson  Tait^  in  1879  performed  the  first  successful  operation  of  cholecystotomy, 
and  to  Tait  more  than  to  any  other  surgeon  of  this  period  is  due  the  credit  of  placing 
the  surgery  of  the  liver  and  gall-bladder  on  a  firm  basis.  Developing  a  technic 
essentially  similar  to  that  followed  by  the  leading  surgeons  to-day,  Tait  was  able 
in  1889  to  report  a  series  of  fifty-five  cases  of  cholecystotomy  with  but  three  deaths, 
all  of  these  deaths  occurring  at  late  periods  following  the  operation  and  not  in  any 
way  referable  to  the  operation  itself. 

In  addition  to  these  remarkable  achievements  in  gall-bladder  surgery  Tait  was 
also  able  at  this  time  to  report  seventeen  cases  of  hepatotomy  with  but  two  deaths, 
the  series  comprising  ten  cases  of  hydatid  cysts,  two  cases  of  "cysts,"  two  liver 
abscesses,  two  cases  of  gall-stones  in  the  liver,  and  one  case  of  "  tumor. " 

Following  the  work  of  these  pioneers,  the  development  of  this  phase  of  surgery 
has  been  largely  along  the  line  of  improvements  in  technic  and  the  development  of 
special  operative  procedures  applicable  to  different  types  of  lesions. 

Cholecystectomy  was  first  performed  by  C.  I/angenbuch^  in  1882,  although  it  is 

'  Thudichum,  J.  L.  W.:  "Pathology  and  Treatment  of  Gall-stones,"  Brit.  Med.  Jour..  Nov. 
19,  1859,  935. 

^  Sims,  J.  Marion:  "Remarks  on  Cholecystotomy  in  Dropsy  of  the  Gall-bladder."  Brit.  Med. 
Jour.,  June  8,  1878,  811.  "Cholecystotomie  pour  I'hydropsie  de  la  vesicule  biliare,"  Rev.  de  Litt, 
Med.  Paris,  1878,  iii,  564;   1879,  iv,  34,  78,  107,  250,  278,  400. 

3Keen,W.  W.:  "A  Case  of  Cholecystotomy,  with  Remarks,"  Amer.  Jour.  Med.  Sci.,  1879, 
Ixxvii,  134. 

*  Tait,  Lawson:  "The  Surgery  of  the  Liver,"  Edinburgh  Med.  Jour.,  1889,  xxxv,  305,  407. 
^Langenbuch,  C:    "Ein   Fall  von  Extirpation  der  Gallenblase  wegen  chronischer  Chole- 
lithiasis: Heilung,"  Berlin,  klin.  Wochenschr.,  1882,  xix,  725. 


278  OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

said  that  as  early  as  1826  Campaignac^  endeavored  in  vain  to  prevail  upon  the  sur- 
geons of  his  day  to  take  up  the  operation. 

The  operation  of  cholecystenterostomy  was  advocated  by  Gaston^  in  1884,  and 
afterward  perfected  by  the  introduction  of  the  Murphy  button.  Choledochotomy, 
conceived  by  Langenbuch  in  1884,  was  first  typically  performed  by  Courvoisier,^ 
in  1889. 

The  work  of  Kocher,  Kehr,  Parkes,  Mayo-Robson,  Fenger,  Riedel,  and  others 
has  done  much  toward  the  development  of  this  field  of  surgery. 


ETIOLOGY  OF  GALL-STONES  AND  DISEASES  OF  THE  BLADDER  AND  BILE-DUCTS. 

In  considering  the  etiology  of  gall-bladder  disease  it  is  important  to  bear  in  mind 
its  anatomic  relation  and  its  mechanical  provisions.  So  long  as  its  anatomic  rela- 
tions are  normal,  and  the  organ  is,  mechanically  considered,  approximately  perfect, 
there  is  no  occasion  for  treatment,  because  the  gall-bladder  becomes  distended  with 
bile,  which  is  a  non-irritating  fluid,  and  empties  itself  regularly.  These  functions 
give  rise  to  neither  pain,  irritation,  nor  discomfort. 

Normally,  the  gall-bladder  is  suspended  from  the  under  surface  of  the  liver  as 
a  very  slightly  distended,  pyriform  sac  which  empties  its  fluid  rapidly  into  the  duo- 
denum. The  muscles  of  the  gall-bladder  are  very  active  and  well  able  to  empty 
its  contents. 

It  seems  to  have  been  proved  beyond  a  doubt  that  this  pouch  shares  the  fate 
of  all  similarly  constructed  organs  in  the  body — the  stomach,  the  urinary  bladder, 
the  pelvis  of  the  kidney,  the  vermiform  appendix.  So  long  as  there  is  nothing  to  pre- 
vent them  from  emptying  their  contents  they  are  almost  certain  to  remain  nor- 
mal, but  as  soon  as  an  obstruction  occurs  which  interferes  with  the  natural  empty- 
ing of  the  organ,  trouble  is  likely  to  ensue.  In  other  words,  an  interference  with 
drainage  is  sure  to  cause  a  certain  amount  of  residual  substance  which  favors  the 
accumulation  of  bacteria  and  injury  to  the  lining  of  the  gall-bladder. 

In  health  it  is  probable  that  in  the  majority  of  cases  the  bile  is  sterile.  Gushing^ 
states  that  the  bile  itself,  contrary  to  the  wide-spread  belief  in  its  antiseptic  prop- 
erties, is  a  good  culture-medium  for  most  organisms.  It  is  surprising  that  the 
bile  should  ordinarily  be  sterile,  as  Gilbert  has  demonstrated,  if  the  probability 
that  microorganisms  are  frequently  being  passed  out  with  it  from  the  liver  is 
considered. 

The  bile  remains  sterile,  however,  only  so  long  as  it  flows  unobstructed  through 
the  ducts.     It  has  been  shown  experimentally  that  as  soon  as  the  outward  flow 

^Campaignac:  Cited  by  Geo.  Ryerson  Fowler.  "Historical  and  Critical  Observations  upon 
the  Surgery  of  the  Liver  and  Biliary  Passages,"  Brooklyn  Med.  Jour.,  1900,  xiv,  932. 

^  Gaston,  James  McFadden:  "Experimental  Cholecystotomy,"  Atlanta  Med.  and  Surg.  Jour., 
1884,  xxiii,  336,  385. 

'  Courvoisier,  L.  G.:  "Pathologie  und  Chirurgie  den  Gallenwege,"  Leipzig,  1890. 

^  Cushing,  Harvey:  "Observation  upon  the  Origin  of  Gall-bladder  Infections  and  upon  the 
Experimental  Formation  of  Gall-stones,"  Johns  Hopkins  Hosp.  Bull.,  1899,  x,  Nos.  101,  102,  p. 
166. 


ETIOLOGY  OF  GALL-STONES  AND  DISEASES  OF  BLADDER  AND   BILE-DUCTS.     279 

of  bile  has  been  obstructed  by  ligation  of  the  common  duct,  the  bile  above  the 
obstruction  becomes  infected.  Bacteria  may  enter  the  gall-bladder  in  two 
ways:  (1)  Along  the  common  duct  from  the  duodenum.  (2)  By  the  blood-cur- 
rent, chiefly  through  the  portal  vein.  The  fact  that  the  bacillus  coli  is  the  most 
common  bacterial  inhabitant  of  the  gall-bladder  and  of  gall-stones  suggests  that 
an  intestinal  origin  is  most  frequent. 

The  injury  which  results  from  the  accumulation  of  bile  in  the  gall-bladder  may 
be  simply  catarrhal  at  first,  but  will  later  become  destructive  to  the  mucous  mem- 
brane and  give  rise  to  ulceration ;  the  latter  in  turn  will  result  in  cicatricial  contrac- 
tion and  further  obstruction.     In   this   way   the   condition   becomes   progressive. 

If,  in  the  mean  time,  the  mucus  and  debris  in  the  gall-bladder  have  been  molded 
into  gall-stones,  the  lining  of  the  gall-bladder  is  not  only  in  contact  with  the  rela- 
tively non-irritating  bile,  but  also  with  these  hard  bodies,  which  are  of  a  very  irregu- 
lar form. 

Clinical  experience  has  shown  the  correctness  of  this  theory,  for  in  most  of  our 
cases  there  has  been  a  distinct  interference  with  the  natural  drainage  of  the  gall- 
bladder. In  many  cases  this  was  caused  by  a  displacement  downward  of  the 
viscus  by  adhesions  to  the  omentum  or  the  transverse  colon  or  both.  In  other 
cases  the  gall-bladder  was  pedunculated;  such  a  condition  has  been  attributed 
to  the  effects  of  tight  lacing,  and  as  in  many  cases  it  occurs  only  in  women,  the 
view  is  probably  correct. 

Bacteria,  especially  the  colon  bacillus,  are  present  with  great  regularity  in 
diseased  gall-bladders  and  in  gall-stones.  It  has  been  found  that  a  large  propor- 
tion of  gall-stone  patients  have  suffered  previously  from  typhoid  fever.  More  than 
35  per  cent,  of  my  cases  have  suffered  from  acute  or  chronic  appendicitis.  It 
is  difficult  to  say  sometimes  whether  typhoid  fever,  cholecystitis,  and  appendicitis 
are  not  simply  simultaneous  infections,  or  whether  the  infection  of  the  gall- 
bladder is  secondary  to  the  other  infections. 

In  experiments  upon  animals  it  has  been  found  that  simple  infection  of  the 
gall-bladder  gives  rise  to  no  pathologic  condition,  provided  there  is  no  obstruc- 
tion to  the  biliary  or  the  cystic  duct.  The  constant  flow  of  new  bile  seems  to  be 
sufficient  to  dilute  and  wash  away  the  infectious  material  to  a  sufficient  extent  to 
make  the  infection  harmless. 

It  is  quite  different  so  soon  as  there  is  an  obstruction  to  the  ducts.  When  there 
is  residual  bile  in  which  microorganisms  can  multiply,  a  pathologic  condition  will 
ensue  which  may  develop  simply  into  a  catarrhal  inflammation  of  the  mucous 
lining  of  the  gall-bladder,  or  it  may  result  in  the  formation  of  gall-stones  or  in  a 
severe  inflammation  of  the  gall-bladder  involving  anatomic  structures  beyond 
the  mucous  membrane.  In  man  this  obstruction  may  result  from  the  inflammation 
of  the  mucous  mernbrane  of  the  common  duct  due  to  an  infection  from  the  ali- 
mentary canal,  or,  as  I  have  seen  in  a  number  of  cases,  the  gall-bladder  may  be 
drawn  downward  bv  adhesions,  causing;  a  short  bend  in  the  common  duct,  or  more 
usually  in  the  cystic  duct,  or  by  an  adhesion  between  the  duodenum,  stomach,  and 


280  OPERATIONS    rPON    THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER> 

liver.  This  condition  is  often  due  to  a  gastric  ulcer.  Again,  the  gall-bladder  may 
be  forced  down  out  of  its  normal  position  on  account  of  tight  lacing,  and  the  mucus 
and  debris,  accumulating  in  the  pouch  containing  residual  bile,  may  be  expelled  at 
intervals  and  may  clog  the  biliary  or  the  common  duct,  and  thus  form  the  obstruc- 
tion necessary  to  make  the  infectious  material  effective.  I  have  repeatedly  observed 
a  complete  obstruction  of  the  common  duct  produced  in  such  a  manner.  Moreover, 
I  have  observed  some  of  the  most  violent  paroxysms  of  gall-stone  colic  in  cases 
of  this  kind. 

If  the  obstruction  persists  in  the  presence  of  infectious  material  in  the  gall- 
bladder, a  suppurative  inflammation  may  ensue,  resulting  in  an  empyema  of 
the  gall-bladder;  if  the  infection  is  severe,  especially  if  there  be  present  a  spas- 
modic contraction  of  the  gall-bladder,  the  entire  mucous  lining  of  the  latter  may 
become  gangrenous,  as  I  have  repeatedly  observed  in  acute  cases. 

The  condition  may  in  turn  extend  to  the  other  layers  of  the  gall-bladder,  result- 
ing in  a  gangrene  of  the  entire  organ,  or  it  may  affect  only  a  small  portion  of  the 
gall-bladder.  ^\Tien  the  latter  is  true,  the  contraction  of  the  non-affected  part 
of  the  gall-bladder  is  likely  to  cause  a  perforation  at  the  gangrenous  point. 

It  is  of  practical  importance  to  know  that  these  spasmodic  contractions  of  the 
gall-bladder  correspond  with  contractions  of  the  stomach,  and  that  they  w^ill  sub- 
side when  the  stomach  is  at  rest,  only  to  recur  when  this  condition  of  rest  in  the  stom- 
ach is  interrupted. 

Age  and  sex  undoubtedly  have  some  influence  upon  the  formation  of  gall- 
stones. Hartmann^  found  the  average  age  of  his  male  patients  who  earned  their 
living  by  manual  labor  to  be  at  the  time  of  operation  forty  years,  and  the  period  of 
duration  of  symptoms  to  be  six  years.  Of  the  leisure  class,  the  average  age  was 
thirty-seven,  and  the  period  of  duration  of  symptoms  was  nine  years.  In  women 
of  the  working-class  the  average  age  was  thirty-five  and  a  half  and  the  duration  of 
symptoms  seven  years;  of  the  better  class,  the  age  w^as  thirty-seven  and  the  duration 
of  symptoms  nine  years.  The  time  of  the  onset  of  stone  was,  therefore,  in  all  cases 
before  the  age  of  thirty-five. 

jMoynihaH"  found  in  fifty  cases  that  the  average  age  of  the  patient  was  forty-five 
years,  and  the  duration  of  symptoms  five  and  one-half  years,  making  the  time  of 
onset  on  the  average  about  forty  years. 

In  looking  over  a  series  of  fifty  of  my  own  cases,  it  was  found  that  the  average 
age  at  the  time  of  operation  was  forty-six  years  and  the  average  duration  of  symptoms 
was  six  and  one-half  years.  In  this  same  series  of  cases  there  were  four  times  as 
many  females  as  males. 

Gall-stones  have  been  observed  in  the  new-born.  StilP  reported  three  cases 
of  gall-stones  in  infants.     In  one  child,  female,  aged  nine  months,  whose  symptoms 

^  Hartmann,  O.:  " Bakteriologische  Studien  an  der  Hand  von  46  Gallenstein-operationen 
nebst  einem  Beitrag  iiber  atiologische  Fragen  des  lithogenen  Katarrhs  der  Gallenblase,"  Deutsche 
Zeit.  f.  Chir.,  1903,  Ixviii,  230. 

^  Moynihan,  B.  G.  A.:   "Gall-stones  and  their  Surgical  Treatment,"  Phila.,  1905,  p.  53. 

3  Still,  Geo.  F.:  "Biliary  CalcuU  in  Children,"  Trans.  Path.  Soc.  of  London,  1899, 1,  151. 


SYMPTOMS    AND    SIGNS    OF   GALL-BLADDER   DISEASE.  281 

were  vomiting  and  wasting,  there  were  purpuric  patches  but  no  jaundice.  Autopsy 
showed  the  gall-bladder  filled  with  golden-yellow  bile  containing  eleven  small  calculi. 
The  second  child,  female,  aged  eight  months,  died  of  acute  miliary  tuberculosis. 
The  gall-bladder  was  found  to  contain  golden-yellow  bile,  mucus,  and  small  calculi. 
The  third  child,  male,  aged  five  months,  died  from  marasmus  and  broncho- 
pneumonia.    The  gall-bladder  contained  rather  dark  bile  and  three  calculi. 


SYMPTOMS  AND  SIGNS  OF  GALL-BLADDER  DISEASE. 

The  frequency  with  which  gall-stones  are  overlooked  draws  our  attention  to  the 
fact  that  it  will  be  necessary  to  change  the  basis  of  our  diagnosis,  because  the  old 
plan  must  continue  to  result  in  wrong  conclusions. 

In  studying  the  histories  of  a  series  of  gall-stone  cases  it  will  be  found  that  the 
early  manifestation  of  the  presence  of  gall-stones  will  practically  never  be  referred 
by  the  patient  to  the  region  of  the  gall-bladder  or  bile-ducts.  The  patients  refer 
their  trouble  to  the  region  of  the  stomach  and  not  to  the  liver.  Perhaps  the  earliest 
symptom,  which  has  persisted  for  years,  is  "indigestion."  It  is  not  uncommon 
for  these  patients  to  come  to  the  surgeon  with  a  diagnosis  of  an  attack  of  indigestion, 
gastric  catarrh,  neuralgia  of  the  stomach,  spasms,  etc. 

The  symptoms,  complications,  and  danger  of  gall-stones  differ  greatly  according 
to  the  location  of  the  stones  in  the  gall-bladder,  cystic  or  common  ducts.  Gall- 
stones in  the  gall-bladder  in  the  absence  of  infection  may  produce  so  little  discomfort 
that  they  may  persist  for  years  without  being  discovered.  As  soon  as  catarrh  or 
some  acute  infection  occurs,  or  the  stone  passes  from  the  gall-bladder  into  the  cystic 
duct,  there  may  be  a  great  variety  of  symptoms,  varying  from  mere  spasms,  fre- 
quently called  attacks  of  indigestion,  to  very  severe  colic,  agonizing  in  character, 
so  severe  as  even  to  lead  to  collapse. 

Pain — to  be  distinguished  from  colic — may  be  local  or  referred.  The  local 
pain  may  be  dull  in  character,  rather  diffuse,  and  exaggerated  upon  taking  food. 
It  is  this  variety  of  pain  which  is  apt  to  be  mistaken  for  that  due  to  disease  of  the 
stomach.  The  dull  pain  is  usually  due  to  some  irritation  or  inflammation;  the 
gall-bladder  becoming  more  or  less  tense  by  some  obstruction  of  the  cystic  duct 
interfering  with  the  free  exit  of  bile,  perhaps  due  to  an  impaction  of  a  stone  in  the 
cystic  duct.  Tenderness  in  these  cases  is  not  always  found  except  on  deep  pres- 
sure in  the  region  of  the  gall-bladder. 

Murphy^  writes:  "The  most  characteristic  and  constant  sign  of  gall-bladder 
hypersensitiveness  is  the  inability  of  the  patient  to  take  a  deep  inspiration  when  the 
physician's  fingers  are  hooked  up  deep  beneath  the  right  costal  arch  below  the 
hepatic  margin.  The  diaphragm  forces  the  liver  down  until  the  sensitive  gall- 
bladder reaches  the  examining  fingers,  when  the  inspiration  suddenly  ceases  as 
though  it  had  been  shut  off.  I  have  never  found  this  sign  absent  in  a  case  of  cal- 
culus or  in  infectious  cases  of  gall-bladder  or  duct  disease." 

1  Murphy,  J.  B.:   "The  Diagnosis  of  Gall-stones,"  Med.  News,  vol.  i,  1903,  p.  85. 


282  OPERATIONS    UPON    THE    BILE-DUCTS,    GALL-BLADDER,    AND    LIVER. 

The  pain  is  frequently  more  acute  than  that  described  above,  which  means  that 
there  is  a  more  marked  irritation  and  inflammation  of  the  gall-bladder  or  the  bile- 
ducts,  and  perhaps  of  the  surrounding  peritoneum. 

The  pain  may  be  referred  to  various  regions.  It  frequently  radiates  to  the  right 
subscapular  region  and  occasionally  to  the  left;  to  the  epigastric  region  or  umbili- 
cus; to  the  front  of  the  chest  and  neck  or  dowm  the  arm, 

Boas^  writes :  "Least  recognized  as  a  s^miptom  of  cholelithiasis  is  tenderness  over 
the  posterior  surface  of  the  liver. "  To  demonstrate  it  the  finger  should  be  pressed 
against  a  point  to  the  right  of  the  tenth  dorsal  spine;  then  against  successive  points 
in  lines  running  horizontally  outward,  opposite  the  other  spinous  processes.  It 
will  then  be  evident  which  side,  if  either,  is  the  more  tender. 

Colic  in  gall-stone  disease  is  not  as  common  as  formerly  supposed.  I  have 
found  that  over  one-half  of  my  cases  have  never  experienced  severe  biliary  colic. 

The  colic,  when  severe,  causes  the  most  intense  suffering.  It  causes  a  sudden 
severe  pain  and  not  infrequently  produces  a  condition  of  collapse.  The  patient 
is  cold  and  yet  has  profuse  sweating.  The  location  of  the  pain  differs  greatly. 
When  a  colic  is  due  to  a  spasm  of  the  gall-bladder  or  cystic  duct,  it  is  most  apt  to 
begin  along  the  right  costal  margin  and  radiate  to  the  right  subscapular  region. 
When  due  to  spasms  of  the  common  duct,  it  is  more  apt  to  be  located  centrally 
and  radiate  to  the  midscapular  region.  It  may  be  epigastric  throughout  or  may 
even  be  situated  in  the  left  upper  quadrant  of  the  abdomen. 

The  cause  of  gall-stone  colic  has  been  much  discussed,  yet  there  seems  to  be  no 
agreement  upon  this  subject. 

Kehi^  and  other  authors  take  the  view  that  the  colics  are  due  to  an  inflammatory 
response  to  irritation  in  the  gall-bladder  or  in  its  ducts. 

Considering  the  abruptness  ■\,\"ith  which  these  colics  begin,  and  the  suddenness 
of  their  relief,  it  would  seem  more  probable  that  the  pain  was  due  to  a  spasm  of  the 
gall-bladder  or  its  ducts  during  the  attempt  at  the  expulsion  of  a  calculus  or  of  thick 
bile,  sand,  or  mucus.  This  suddenness  with  which  the  pain  begins  and  subsides  is 
certainly  incompatible  Tvdth  anything  of  an  inflammatory  nature,  and  can  only  be 
explained  by  a  spasm  due  to  the  sudden  entrance  and  exit  of  some  foreign  body, 
but  the  presence  of  inflammation  naturally  increases  the  obstruction  and  the  pain. 

It  is  of  practical  interest  to  know  that  these  spasmodic  contractions  of  the  gall- 
bladder correspond  with  the  contraction  of  the  stomach,  and  that  they  subside  when 
the  stomach  contraction  is  interrupted. 

I  have  repeatedly  observed  that  attacks  of  gall-stone  colic  which  would  not 
subside  from  the  use  of  as  much  as  one-half  to  three-fourths  of  a  grain  of  morphin 
given  hypodermically,  would  stop  directly  upon  irrigating  the  stomach  with  very 
hot  water,  thus  putting  the  stomach  at  rest,  only  to  recur  the  moment  any  form  of 

^  Boas,  J.:  "Beitrage  zur  Kenntniss  des  Cholelithiasis,"  Miinch.  med.  Wochenschr.,  1902, 
No.  15,  xlix,  604. 

^  Kehr,  Hans:  "A  Re%aew  of  720  Laparotomies  for  Gall-stones,  with  a  Consideration  of  90 
Cases  of  Drainage  of  the  Hepatic  Duct,"  Miinch.  med.  Wochenschr.,  1902,  xlix,  No.  41,  42,  43,  S. 
1688,  1748, 1800. 


SYMPTOMS   AND    SIGNS    OF   GALL-BLADDER   DISEASE.  283 

food  was  taken  into  the  stomach,  giving  rise  to  the  normal  contraction  of  this  organ. 
In  these  cases  the  renewed  use  of  gastric  lavage  and  further  abstaining  from  food 
would  result  in  permanent  interruption  of  the  spasmodic  contraction  of  the  gall- 
bladder, and  would  permanently  stop  the  gall-stone  colic. 

This  point  is  of  practical  importance,  because  it  not  only  indicates  an  efficient 
means  for  securing  the  relief  of  pain,  but  also  one  for  preventing  destruction  of 
gall-bladder  tissue  and  possible  perforation. 

Stomach  Symptoms. — Perhaps  the  most  common  symptom  of  gall-stone 
disease  is  "indigestion."  The  attacks  of  indigestion  begin  with  pain  in  the  epi- 
gastrium, followed  by  nausea  and  finally  by  vomiting,  which  usually  brings  relief. 
The  nausea  and  vomiting  are  partly  reflex  in  origin  and  partly  due  to  direct  irrita- 
tion of  the  stomach. 

Other  gastric  disturbances  associated  with  gall-bladder  disease  are  frequently 
manifested  by  distress  in  the  epigastric  region,  described  as  a  feeling  of  weight  or 
a  burning  sensation  after  eating;  also  gaseous  distention  of  the  abdomen.  The 
subjects  of  gall-stone  disease  are  also  usually  troubled  with  eructations  of  gas  after 
eating. 

It  is  not  uncommon  for  these  patients  to  have  repeated  attacks  of  nausea  and 
vomiting  and  attacks  of  indigestion  accompanied  by  severe  pain  in  the  epigas- 
trium, often  called  gastralgia  or  neuralgia  of  the  stomach.  After  an  attack  of  nausea 
and  vomiting  and  epigastric  pain  there  is  apt  to  be  an  interim  when  the  patient  is 
free  from  stomach  symptoms  or  has  only  the  milder  symptoms  of  bloating  and  dis- 
tress after  eating. 

There  may  be  a  dull  pain,  beginning  in  the  epigastric  region  and  extending 
around  the  right  side  at  about  the  level  of  the  tenth  rib,  passing  to  a  point  near  the 
spine  and  progressing  upward  underneath  the  right  shoulder-blade. 

Jaundice. — Jaundice,  upon  which  so  much  stress  has  been  placed  in  the  diag- 
nosis of  gall-stones,  is  absent  in  the  greater  number  of  cases  at  the  time  they  consult 
the  surgeon.  My  experience  has  been  that  only  a  small  proportion  of  our  cases 
have  ever  been  severely  jaundiced,  and  in  more  than  one-half  of  them  jaundice 
has  never  been  observed. 

Mayo^  says:  "Jaundice  has  no  part  in  the  diagnosis  of  gall-bladder  stone,  and 
when  present  means  a  complication."  Kehr^  states  that,  in  his  experience,  jaun- 
dice is  absent  in  from  80  to  90  per  cent,  of  gall-stone  cases,  and  even  in  choledocho- 
lithiasis — those  cases  in  which  the  stones  are  lodged  in  the  choledochus  and  hepat- 
icus — the  jaundice  is  absent  in  33^  per  cent.  He  further  states  that  the  passage 
of  stones  without  a  concomitant  jaundice  is  not  at  all  uncommon.  Deaver'  states 
that  jaundice  is  absent  in  the  majority  of  gall-stone  cases. 

The  fallacy  in  regard  to  icterus  in  connection  with  gall-stones  has  been  handed 

^  Mayo,  Wm.  J.  and  Charles  H.:  "The  Diagnosis  of  Gall-stone  Disease,"  St.  Paul  Med.  Jour., 
1905,vii,79. 

^  Loc.  cit. 

^  Deaver,  John  B.:  "The  Significance  of  Jaundice  as  a  Symptom  in  Disease  of  the  Biliary 
Tracts,"  N.  Y.  Med.  Jour.,  1903,  Ixxviii,  301. 


284  OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

down  to  successive  generations  of  physicians  and  the  laity  so  long  that  the  majority 
of  patients  refuse  to  believe  that  they  can  have  gall-stones  and  not  be  jaundiced. 
Jaundice  in  cholelithiasis  is  due  to  an  impaction  of  a  stone  in  the  common  or  hepatic 
ducts,  or  to  an  infection  of  these  ducts,  and  occasionally  to  an  impaction  of  a  large 
stone  in  the  cystic  duct  pressing  upon  the  common  or  hepatic  ducts.  When  jaun- 
dice is  due  to  gall-stones,  it  is  most  always  preceded  by  a  colic.  The  colic  may 
come  on  a  few  hours  or  days  before  the  appearance  of  jaundice.  The  yellow  tinge, 
as  a  rule,  comes  on  gradually  and  increases  until  the  obstruction  is  relieved,  and 
then  gradually  disappears. 

Remittent  icterus,  according  to  Fenger,^  slight,  or,  as  it  might  be  called,  incom- 
plete attacks  of  icterus,  occurring  as  often  as  once  or  twice  a  week,  is  characteristic 
of  stone  in  the  common  duct,  and,  in  his  opinion,  of  floating  choledochus  stone. 
Fenger  describes  this  condition  as  occurring  in  the  following  manner:  A  stone  be- 
comes impacted  in  the  common  duct,  and  the  accumulation  of  bile  on  the  proximal 
or  liver  side  presses  the  walls  of  the  duct  away  from  the  stone,  allowing  the  bile  to 
pass  around  the  stone.  Following  this,  the  jaundice  is  due  to  a  "ball-valve"  action 
of  the  stone. 

When  jaundice  is  due  to  carcinoma  involving  the  gall-ducts,  or  results  from  pres- 
sure from  a  growth  of  the  head  of  the  pancreas,  the  jaundice  will  appear  gradually 
and  without  pain.  There  will  be  no  remission  or  intermission,  but  the  color  will 
steadily  deepen  from  day  to  day  until  the  skin  becomes  a  greenish-yellow  color.  It  is 
very  rare  to  meet  with  jaundice  of  a  deep  greenish-yellow  color,  except  in  the  pres- 
ence of  malignant  disease. 

Fever. — Fever  is  not  ordinarily  present  early  in  a  simple  attack  of  gall-stones. 
If  the  attack  is  prolonged  and  infection  occurs,  fever  develops.  When  the  infection 
is  confined  entirely  to  the  gall-bladder,  the  rise  of  temperature  is  usually  not  high. 
Mayo  explains  this  condition  as  being  due  to  the  fact  that  there  are  few  lymphatic 
channels  in  the  gall-bladder  and  consequently  slow  absorption. 

When  there  is  an  infection  of  the  ducts  there  may  be  rigor  accompanying  or 
following  the  colic,  with  a  very  abrupt  rise  of  temperature  to  its  maximum,  and  then 
with  almost  equal  rapidity  a  return  to  normal.  These  attacks  may  simulate  a  malar- 
ial infection.  Between  the  attacks  of  infection  the  temperature  remains  practically 
normal.  Persistent  fever  associated  with  other  gall-stone  symptoms  may  mean 
an  empyema  or  severe  cholecystitis  as  an  extension  of  the  infection  to  the  channels 
of  the  liver. 

Moynihan^  speaks  of  a  temperature  chart,  showing  these  attacks  of  infection 
represented  by  an  abrupt,  peak-like  elevation  with  the  normal  interspace  as  most 
characteristic.  He  calls  it  a  "steeple"  chart,  and  further  states  that  the  occurrence 
of  these  angular  elevations  in  the  chart  recording  the  temperature  is  quite  pathog- 
nomonic of  gall-stone  disease. 

1  Fenger,  Christian:  "Stones  in  the  Common  Duct  and  their  Surgical  Treatment,"  Amer. 
Jour.  Med.  Sci.,  1896,  cxi,  125,  286. 

2  Moynihan,  B.  G.  A.:  "Gall-stones  and  their  Surgical  Treatment,"  1905,  p.  133. 


SYMPTOMS    AND    SIGNS    OF    GALL-BLADDER   DISEASE.  285 

Murphy^  speaks  of  the  "temperature  angle  of  cholangic  infections. "  He  writes: 
"The  temperature  in  an  hour  will  rise  to  104°  or  105°,  remain  stationary  for  a  few 
hours,  and  then  drop  as  suddenly  to  normal,  and  remain  normal  for  hours,  days,  or 
even  weeks,  when  it  will  go  through  the  same  rapid  variation,  and  continue  to  repeat 
itself  at  irregular  intervals."  And  again:  "These  temperature  changes  are  so 
characteristic  that  I  have  given  them  the  name  of  the  temperature  angle  of  cholangic 
infection." 

Tumors. — A  palpable  enlargement  of  the  gall-bladder  occurs  as  the  result  of 
some  obstruction  of  the  cystic  duct.  This  obstruction  may  be  from  an  impacted 
stone,  a  cicatricial  contraction  of  the  cystic  duct,  or  a  twist  of  the  neck  of  the  gall- 
bladder, or  from  an  abnormal  growth.  It  occurs  also  when  there  is  an  obstruction 
of  the  common  duct  caused  by  some  pressure  from  outside  of  the  duct. 

An  enlarged  gall-bladder  is  generally  pear-shaped,  lies  just  below  the  edge  of  the 
liver,  and  moves  up  and  down  during  the  act  of  respiration  with  the  liver. 

Enlargement  of  the  liver  is  not  a  constant  sign,  and  is  rarely  present  as  long  as 
the  disease  is  confined  to  the  gall-bladder  and  the  cystic  duct. 

Special  Symptoms. — Obstruction  of  Cystic  Duct. — Obstruction  of  the  cystic 
duct  causes  retention  of  fluid  in  the  gall-bladder,  with  a  rapid  distention  of  the  gall- 
bladder behind  the  obstruction.  This  fluid  consists  of  mucus  if  the  infection  is 
slight,  or  of  mucopus  if  the  infection  is  more  severe.  The  bile  that  may  be  in  the 
gall-bladder  at  the  time  the  obstruction  occurs  is  rapidly  absorbed,  leaving  either 
the  clear  mucus  or  turbid  fluid,  according  to  the  amount  of  infection.  The  dis- 
tended gall-bladder  may  reach  an  enormous  size  and  usually  becomes  palpable. 
If  the  inflammatory  process  be  very  acute,  a  severe  cholecystitis  or  even  gangrene 
of  the  gall-bladder  may  result.  Associated  with  this  condition  a  local  protective 
peritonitis  usually  develops,  leading  to  the  formation  of  visceral  adhesions. 

The  early  symptoms  of  impaction  of  stone  in  the  cystic  duct  are  usually  very 
acute,  beginning  with  a  severe  colic  underneath  the  right  costal  arch,  and  radiating 
up  into  the  right  subscapular  region.  There  is  rarely  any  jaundice  accompanying 
or  following  the  pain.  The  pain  loses  its  colicky  character  rather  early,  and  there 
may  be  only  a  dull  ache  or  sense  of  discomfort.  If  the  obstruction  becomes  chronic 
and  there  is  little  or  no  infection,  a  hydrops  of  the  gall-bladder  develops.  If  it  is 
associated  with  infection  of  any  severity,  an  empyema  of  the  gall-bladder  is  apt  to 
be  the  result.     All  of  these  symptoms  may  occur  without  any  evidence  of  jaundice. 

Rarely  a  stone  in  the  cystic  duct  may  be  so  large  as  to  press  upon  the  common 
duct  and  cause  jaundice.  Robson^  states  that  in  rare  cases  a  stone  impacted  in  the 
cystic  duct  may,  by  pressure  on  the  common  duct  and  on  the  portal  vein,  cause  both 
jaundice  and  ascites  and  thus  may  lead  to  an  error  in  diagnosis. 

I  have  seen  a  case  in  which  the  gall-bladder  was  adherent  to  the  anterior  ab- 
dominal wall  an  inch  below  the  umbilicus.     There  was  a  perforation  of  the  abdomi- 

'  Murphy,  J.  B.:   "The  Diagnosis  of  Gall-stones,"  Med.  News,  1903,  Ixxxii,  830. 
'  Robson,  A.  W.  Mayo:    "Common  Duct  CholeUthiasis:    Its  Symptoms,  CompHcations,  and 
Treatment,"  Surg.  Gynec.  and  Obstet.,  1906,  ii,  1. 


286  OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

nal  wall  at  the  point,  half  an  inch  in  diameter,  communicating  with  the  hernial  cavity 
underneath  the  deep  fascia,  one  and  one-half  inches  in  diameter,  which  contained 
seven  stones  and  a  quantity  of  pus  and  granulation  tissue.  I  have  seen  two  other 
similar  cases  and  one  gall-bladder  which  had  perforated  into  the  stomach,  and  others 
which  have  perforated  into  other  portions  of  the  aHmentary  canal  have  been  de- 
scribed by  different  observers. 

I  have  found  a  gall-stone  in  the  ileum  one  and  one-half  inches  in  diameter  which, 
of  course,  must  have  entered  this  viscus  by  ulceration,  as  it  was  too  large  to  pass 
through  the  cystic  or  common  ducts.  The  operation  was  performed  for  the  reHef 
of  an  acute  intestinal  obstruction,  and  the  patient's  condition  was  too  serious  to  per- 
mit of  the  necessary  manipulation  to  locate  the  point  of  perforation. 

Acute  Cholecystitis. — The  symptoms  found  in  an  acute  cholecystitis  are  similar 
to  those  present  in  the  early  stage  of  cholelitliiasis.  In  addition  to  these,  there  is 
an  enlargement  of  the  gall-bladder,  making  it  palpable  and  very  tender  upon  pres- 
sure. There  is  often  acute  severe  pain  in  the  gall-bladder,  which  may  radiate  to 
the  back,  chest,  or  abdomen.  Associated  with  the  pain  and  tenderness  there  may 
be  a  right-sided  rigidity  which  may  simulate  appendicitis.  The  history  will  help 
us  in  the  diagnosis,  as  it  will  be  found  that  the  pain  was  originally  in  the  gall-bladder 
region  and  later  became  diffused.  As  a  rule,  the  pain,  tenderness,  and  rigidity 
of  the  abdomen  are  limited  to  an  area  along  the  costal  margin. 

Moynihan^  states  that  the  catarrhal  form,  and  indeed  the  other  forms,  may  arise 
in  the  absence  of  gall-stones,  but  in  the  majority  of  instances  it  is  the  damage  done 
by  a  calculus  that  opens  the  path  to  infection. 

Chronic  Cholecystitis. — In  chronic  cholecystitis  there  is  seldom  present  a  definite 
train  of  symptoms  which  would  ordinarily  direct  one's  attention  to  the  gall-bladder. 
However,  there  is  usually  present  a  rathtx-  constant,  dull,  aching  pain  in  the  right 
hypochondrium,  often  hardly  noticeable.  There  may  be  exacerbations  of  the 
inflammatory  trouble,  when  the  pain  will  be  more  marked.  The  principal  symp- 
tom will  be  in  the  line  of  digestive  disturbances,  manifested  by  a  sensation  of  fullness 
in  the  epigastrium,  more  or  less  bloating  and  distress  coming  on  during  or  immedi- 
ately after  eating,  accompanied  by  eructations  of  gas.  It  is  not  uncommon  for 
these  patients  to  complain  of  sour  stomach. 

Occasionally  these  patients  will  suffer  from  a  typical  attack  of  biliary  colic  from  the 
passage  of  sand-Hke  material  through  the  gall-ducts.  It  is  not  uncommon  in  cases 
of  chronic  cholecystitis  to  find  the  gall-bladder  filled  with  black,  thick,  sandy  bile. 

The  diagnosis  depends  upon  the  various  gastric  disturbances  enumerated  above, 
together  with  the  dull  aching  or  burning  pain  in  the  right  hypochondrium,  and 
the  finding  of  an  area  of  tenderness  in  the  region  of  the  gall-bladder.  This  tender- 
ness is  practically  always  present,  and  can  be  elicited  by  placing  the  finger-tips 
underneath  the  costal  arch,  and,  when  the  abdominal  muscles  are  relaxed,  having 
the  patient  take  a  deep,  full  inspiration,  forcing  the  gall-bladder  against  the  finger- 
tips. 

'  Loc.  cit. 


SYMPTOMS   AND    SIGNS    OP^   GALL-BLADDER    DISEASE.  287 

Stones  in  the  Common  Duct.— The  presence  of  stones  in  the  common  duct  has 
been  variously  estimated.  In  1500  operations  upon  the  gall-bladder  and  bile- 
passages,  Mayo^  met  with  207  cases  of  common-duct  stone. 

Kehr,^  in  720  operations  for  gall-stones,  had  137  common-duct  cases. 

Mayo  Robson^  says:  "In  my  hospital  practice  I  find  that  my  common-duct 
cases  bore  the  proportion  of  one-third  to  the  whole  of  my  operations. " 

In  common-duct  cases  it  is  not  uncommon  to  find  a  history  of  frequent  attacks  of 
pain  which  have  occurred  at  variable  intervals  for  years,  accompanied  by  a  slight 
jaundice.  Suddenly  there  will  be  an  attack  of  severe  pain  with  a  rapid  and  pro- 
nounced jaundice.  This  is  the  time  at  which  the  stone  passes  into  the  common  duct. 
If  the  stone  be  a  small  one,  it  may  pass  on  into  the  intestines  and  the  jaundice 
entirely  clear  up  in  a  few  days.  If  the  stone  becomes  impacted  in  the  common  duct, 
there  will  be  a  complete  obstruction  of  the  passage  of  bile,  resulting  in  severe  jaun- 
dice and  enlargement  of  the  liver. 

It  is  rare  to  meet  with  an  acute  permanent  occlusion  of  the  common  duct  from 
stone.  As  soon  as  the  stone  becomes  impacted,  the  pressure  of  the  bile  causes  a 
dilatation  of  the  duct,  so  that  a  stone,  which  at  first  fits  tightly,  will  be  loose  in 
the  duct,  allowing  the  bile  to  pass  around  it.  We  then  may  have  a  condition  which 
Fenger  describes,  in  which  the  stone  acts  as  a  "ball-valve"  in  the  duct. 

With  a  stone  in  the  common  duct  it  is  questionable  whether  the  jaundice  ever 
entirely  disappears.  There  may  be  intervals  when  the  patient  does  not  notice  any 
icterus,  but  upon  close  examination  the  conjunctiva  will  always  show  it. 

Mayo*  has  found  that  33  J  per  cent,  of  his  common-duct  cases  have  no  perceptible 
jaundice  at  the  time  of  operation. 

With  a  stone  floating  in  the  common  duct  as  a  "ball-valve"  there  will  be  inter- 
mittent attacks  of  pain  with  jaundice  of  a  varying  degree.  These  attacks  are  usually 
accompanied  by  chills,  with  a  sudden  rise  in  temperature,  which  is  apt  to  assume  a 
quite  characteristic  malarial  curve.  During  and  after  these  attacks  there  are  tender- 
ness and  enlargement  of  the  liver. 

One  important  symptom  in  obstruction  of  the  common  duct  is  the  rapid  and 
considerable  loss  in  weight.  Fenger^  ascribed  this  loss  of  weight  to  intermittent, 
frequent  ptomain  intoxication, — that  is,  bile  absorption, — as  well  as  to  the  dis- 
turbed digestion. 

It  is  important  to  bear  this  point  in  mind  as  a  symptom  of  stone  in  the  common 
duct.     The  loss  of  weight  is  very  apt  to  suggest  a  diagnosis  of  malignant  disease. 

^  Mayo,  Wm.  J.  and  Charles  H.:  "A  Review  of  1500  Operations  upon  the  Gall-bladder  and 
Bile  Passages  with  Special  Reference  to  Mortality,"  Ann.  Surgery,  1906,  xliv,  209. 

^Kehr,  Hans:  "A  Review  of  720  Laparotomies  for  Gall-stones  with  Special  Consideration  of 
90  Cases  of  Drainage  of  the  Hepatic  Duct,"  Munch,  med.  Wochenschr.,  1902,  xlix,  No.  41,  42,  43, 
S.  1688,  1748,  1800. 

'Robson,  A.  W.  Mayo:  "Common  Duct  Cholelithiasis:  Its  Symptoms,  Complications,  and 
Treatment,"  Surg.  Gynec.  and  Obstet.,  1906,  ii,  1. 

*  Loc.  cit. 

*  Fenger,  Christian:  "Stones  in  the  Common  Duct  and  their  Surgical  Treatment,"  Amer. 
Jour.  Med.  Sci.,  1896,  cxi,  125  and  286. 


288  OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

The  jaundice  of  malignant  disease  is  not  accompanied  by  pain,  it  steadily  in- 
creases, and  does  not  vary  from  day  to  day,  as  it  usually  does  in  the  case  of  common- 
duct  stones.  When  the  jaundice  is  due  to  some  pressure  from  outside  the  duct, 
as  a  carcinoma  of  the  head  of  the  pancreas,  the  gall-bladder  will  be  distended,  while 
in  cases  where  the  obstruction  is  from  a  stone  within  the  duct,  the  gall-bladder  is 
usually  contracted. 

PATHOLOGY. 

The  inflammatory  lesions  of  the  gall-bladder  and  bile-ducts  are  essentially  those 
of  a  tract  lined  "vvath  mucous  membrane  the  anatomic  relations  of  which  are  such 
as  to  make  it  subject  to  conditions  of  imperfect  drainage. 

Simple  catarrhal  inflammation  limited  to  the  mucous  membrane  is  probably 
of  relatively  frequent  occurrence,  but,  as  a  rule,  it  is  only  when  this  catarrhal  inflam- 
mation is  the  cause  of  obstruction  at  some  point  that  it  assumes  clinical  or  surgical 
importance.  Such  catarrhal  inflammation  is  characterized  by  an  increased  pro- 
duction of  mucus  and,  as  pointed  out  by  Xaunyn,  an  excessive  formation  of  choles- 
terin.  The  "sandy"  appearance  of  the  bile  noted  at  operation  in  these  cases  is  due 
in  part  to  the  cholesterin  crystals  and  in  part  to  epithelial  detritus  and  bile-stained 
bits  of  mucus. 

The  more  severe  inflammatory  lesions  are,  as  a  rule,  dependent  upon  obstruc- 
tion, and  are  of  a  diffuse  type,  involving  all  coats  of  the  gall-bladder  or  ducts.  These 
lesions  are  usually  accompanied  by  more  or  less  extensive  fibrinous  peritonitis, 
resulting  in  the  formation  of  adhesions  to  the  neighboring  organs,  especially  the 
stomach,  duodenum,  colon,  and  omentum. 

The  character  of  the  inflammation  may  vary  from  a  simple  congestion  with 
leukocytic  infiltration  to  the  most  severe  suppurative  or  even  gangrenous  types.  In 
the  presence  of  gall-stone,  ulceration  of  the  mucous  and  even  of  the  submucous  and 
muscular  coats  is  a  frequent  and  characteristic  occurrence  and  may  result  in  per- 
foration or  the  formation  of  fistulas,  as  described  elsewhere.  Gangrene  of  the  gall- 
bladder is  but  rarely  met  with,  probably  owing  to  the  free  blood-supply  of  the  organ, 
not  only  through  the  branches  of  the  cystic  artery,  but  also  through  their  anasto- 
mosis with  the  hepatic  vessels  where  the  gall-bladder  is  attached  to  the  liver. 

With  the  subsidence  of  the  acute  attack  and  the  re-establishment  of  free  drainage 
either  by  natural  or  artificial  means,  the  repair  of  even  very  severe  lesions  is  rapid 
and  surprisingly  complete,  as  is  often  demonstrable  in  cases  reoperated  upon  for 
other  causes.  On  the  other  hand,  if  the  causal  factors  of  the  inflammation  persist, 
the  continued  irritation  may  result  in  the  formation  of  irreparable  lesions  due  to  the 
excessive  production  of  scar  tissue. 


INDICATIONS  FOR  OPERATION. 
So  long  as  the  gall-stones  simply  remain  in  the  gall-bladder  without  causing  any 
complications,  the  harm  to  the  patient  is  relatively  slight.     His  comfort  will  not 


INDICATIONS    FOR    OPERATION.  289 

be  greatly  disturbed  on  account  of  the  disturbances  in  his  digestion.  The  pain  will 
not  be  extreme,  and  he  usually  accumulates  an  abundance  of  fat,  especially  in  the 
abdominal  walls.  It  has  consequently  been  held  by  many  authorities  that  it  is  not 
wise  to  make  use  of  radical  measures  for  the  removal  of  gall-stones  so  long  as  they 
do  not  give  rise  to  any  grave  disturbances.  This  undoubtedly  would  be  a  proper 
and  reasonable  view  to  take  were  the  danger  to  the  patient  approximately  the  same 
before  and  after  the  occurrence  of  these  complications.  This,  however,  is  not  the 
case.  Experience  has  shown  us  that  the  mortality  in  cases  which  are  operated 
before  any  serious  complications  arise  is  practically  nil,  while  the  deaths  which 
followed  operation  in  the  complicated  cases  undoubtedly  might  have  been  avoided 
had  the  operation  been  performed  before  these  complications  arose. 

Mayo,^  in  his  review  of  1500  operations  upon  the  gall-bladder  and  bile-passages, 
says:  "It  was  the  mortality  and  the  complications  of  delay  that  placed  the  early 
operation  for  appendicitis  on  a  sound  surgical  footing.  To  remove  the  disease  while 
still  in  the  appendix,  and  before  its  rupture  involved  the  abdominal  cavity,  was  the 
logical  conclusion. 

"The  same  reasons  apply,  and  with  equal  force,  to  the  early  operation  for  gall- 
stone disease.  Remove  the  disease  while  still  in  the  gall-bladder  with  a  mortahty 
of  from  1.47  per  cent,  (cholecystostomy)  to  1.62  per  cent,  (cholecystectomy).  This 
includes  deaths  from  accidental  causes,  acute  perforation,  and  gross  infection.  Ex- 
cluding these  cases,  a  mortality  of  less  than  1  per  cent,  can  be  shown." 

Mayo  Robson^  says:  "As  gall-stones  are  usually  diagnosed  in  their  early  stage 
before  danger  has  arisen,  and  as  their  removal  at  their  early  stage  can  be  effected 
with  very  little  risk,^at  the  outside,  1  per  cent., — it  seems  to  me  that  the  wisest 
course  is  not  to  wait  for  complications  to  arise,  but  to  advise  the  removal  of  the  dis- 
ease at  an  early  period  and  so  prevent  the  serious  sequela?. " 

The  complications  which  are  likely  to  be  caused  by  the  presence  of  gall-stones 
may  be  chronic  in  character,  taking  the  form  of  digestive  disturbances  and  giving 
rise  to  almost  constant  discomfort.  This  condition  is  probably  due  to  the  inter- 
ference with  the  passage  of  food  through  the  pylorus  into  the  duodenum,  causing 
dilatation  of  the  stomach. 

Again,  the  patient  may  be  in  a  slightly  septic  condition,  because  there  is  more  or 
less  absorption  of  the  septic  material  from  the  infected  residual  bile  as  well  as  from 
the  products  of  fermentation  in  the  dilated  stomach.  These  conditions  frequently 
result  in  chronic  invalidism,  making  it  impossible  for  the  patient  to  follow  ordinary 
occupations  and  to  enjoy  life  in  any  way.  The  constant  irritation  of  the  gall- 
bladder, due  to  the  pressure  of  the  gall-stones,  undoubtedly  has  much  to  do  with 
the  development  of  carcinoma  in  this  organ. 

In  cases  of  primary  carcinoma  of  the  gall-bladder  I  have  always  been  able  to 
get  a  history  of  gall-stones  dating  back  many  years,  and  I  have  invariably  found 

^  Mayo,  Wm.  J.  and  Charles  H.:    "A  Review  of  1500  Operations  upon  the  Gall-bladder  and 
Bile-passages  with  Special  Reference  to  Mortality,"  Ann.  Surgery,  1906,  xliv,  209. 
'  Loc.  cit. 

A^OL.  II — 19 


290  OPERATIONS   UPON    THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

these  present  in  the  gall-bladder  in  such  instances  at  the  time  of  the  operation  or 
autopsy.  Aside  from  these  chronic  conditions,  gall-stones  may  at  any  time  cause 
exceedingly  grave  acute  conditions. 

These  complications  are  all  the  result  of  inflammation,  and  the  sequelae  must 
consequently  depend  upon  the  extent  to  which  this  develops. 

I  take  the  following  list  of  complications  from  Mayo  Robson's  excellent  article 
on  this  subject,  because  its  arrangement  is  most  satisfactory: 

1.  Ileus  due  to  paresis  of  the  bowel,  leading  to  enormous  distention  of  the  ab- 
domen and  to  symptoms  and  appearances  of  acute  intestinal  obstruction,  apparently 
the  consequence  of  the  violent  pain. 

2.  Acute  intestinal  obstruction  dependent  on : 

(A)  Paralysis  of  gut  due  to  local  peritonitis  in  the  neighborhood  of  the  gall- 
bladder. 

(B)  Volvulus  of  small  intestine. 

(C)  Stricture  of  intestine  by  adventitious  bands,  originally  produced  as  a 
result  of  gall-stones. 

(D)  Impaction  of  a  large  gall-stone  in  some  part  of  the  intestine  after  ulcerat- 
ing its  way  from  the  bile-channels  into  the  bowels. 

3.  General  hemorrhage,  the  result  of  long-continued  jaundice,  dependent  either 
on  gall-stones  alone,  or  on  cholelithiasis  associated  with  malignant  disease  or  with 
interstitial  pancreatitis. 

4.  LocaHzed  peritonitis,  producing  adhesions  which  may  then  become  a  source 
of  pain  even  after  the  gall-stones  have  been  got  rid  of.  I  believe  that  nearly  every 
serious  attack  of  biliary  colic  is  accompanied  by  adhesive  peritonitis,  as  experience 
shows  that  adhesions  are  found  practically  in  all  cases  where  there  have  been  char- 
acteristic seizures. 

5.  Dilatation  of  stomach  depending  upon  adhesions  around  the  pylorus. 

6.  Ulceration  of  the  bile-passages,  establishing  a  fistula  between  them  and  the 
intestine. 

7.  Stricture  of  the  cystic  or  common  duct. 

8.  Abscess  of  the  liver. 

9.  Localized  peritoneal  abscess. 

10.  Abscess  in  the  abdominal  wall. 

11.  Fistula  at  the  umbiHcus,  or  elsewhere  on  the  surface  of  the  abdomen,  dis- 
charging mucus,  mucopus,  or  bile. 

12.  Empyema  of  the  gall-bladder. 

13.  Infective  and  suppurative  cholangitis. 

14.  Septicemia  or  pyemia. 

15.  Phlegmonous  cholecystitis. 

16.  Gangrene  of  the  gall-bladder. 

17.  Perforative  peritonitis  due  to  ulceration  through  or  to  rupture  of  the  gall- 
bladder or  ducts,  leading  to  extravasation  of  infected  bile  into  the  general  peritoneal 
cavity. 


TREATMENT.  291 

18.  Pyelitis  on  the  right  side  due  to  a  gall-stone  ulcerating,  or  an  abscess  of  the 
gall-bladder  bursting,  into  the  pelvis  of  the  kidney. 

19.  Cancer  of  the  gall-bladder  or  ducts. 

20.  Subphrenic  abscess. 

21.  Pleurisy  or  empyema  of  the  right  pleura. 

22.  Pneumonia  of  lower  lobe  of  right  lung. 

23.  Chronic  invalidism  or  inability  to  perform  any  of  the  ordinary  business  or 
social  duties  of  life. 

24.  Gangrenous  or  suppurative  pancreatitis. 

25.  Chronic  interstitial  pancreatitis. 

26.  Infective  endocarditis. 

27.  Cirrhosis  of  liver. 

28.  Appendicitis  due  to  extension  of  inflammation  from  the  gall-bladder  or  to 
impaction  of  a  gall-stone  in  the  appendix. 


CONTRAINDICATIONS  TO  OPERATION. 
In  disease  of  the  gall-bladder  there  are  some  definite  contraindications  to  opera- 
tion  which,   I  believe,  have  now  been  quite    thoroughly  established  by  clinical 
observation. 

1.  It  is  ordinarily  unwise  to  operate  during  the  attack  of  gall-stone  colic. 

2.  Severe  icterus  is  a  contraindication  to  a  prolonged  operation. 

3.  The  same  is  true  of  prostration  following  long-continued  suffering. 

4.  Cases  complicated  with  carcinoma  belong  to  the  same  class. 

5.  Patients  with  ecchymotic  spots  are  almost  certain  to  die  if  operated  upon. 

In  all  these  cases  if  an  operation  must  be  performed  it  should  be  limited  to  drain- 
age of  the  gall-bladder  and  removal  of  the  stones  in  this  viscus,  and  all  further  man- 
ipulations should  be  postponed  until  the  patient  is  in  a  better  general  condition. 


TREATMENT. 

Gall-stones  and  severe  infections  of  the  bile-tracts  have  come  to  be  looked  upon 
as  purely  surgical  conditions.  However,  it  has  been  my  experience  that  cases  with 
acute  exacerbation  fare  better  if  the  operation  is  deferred  until  the  acute  symptoms 
have  subsided.  In  any  case  complicated  with  an  acute  inflammatory  condition 
I  believe  that  the  same  general  principles  should  be  employed  as  in  inflammatory 
processes  involving  the  peritoneum  from  any  other  cause.  So  long  as  there  is  no 
circumscribed  accumulation  of  pus,  the  treatment  must  consist  in  rest.  This  can 
be  secured  most  readily  by  using  gastric  lavage  in  order  to  remove  remnants  of 
food  or  decomposing  mucus  from  the  stomach;  then  prohibiting  the  use  of  cathar- 
tics and  food  by  mouth, 

I  desire  especially  to  emphasize  the  value  of  securing  absolute  rest  of  the  stomach 
by  the  use  of  gastric  lavage;   and  then  not  placing  any  form  of  nourishment  in  the 


292  OPEKATIONS   UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

Stomach,  but  confining  the  patient  exclusively  to  rectal  alimentation.  In  the  treat- 
ment of  patients  suffering  from  acute  cholecystitis  characterized  by  the  presence  of 
severe  gall-stone  colic,  I  have  seen  many  cases  in  which  the  pain  was  excruciating 
and  large  doses  of  morphin  given  hypodermically  failed  to  give  relief,  but  in  which 
the  pain  disappeared  almost  completely  without  further  opiate  after  the  use  of  gas- 
tric lavage.  In  these  cases  the  pain  does  not  recur  unless  some  form  of  nourish- 
ment is  given  by  mouth;  even  water  often  causes  recurrence  of  pain. 

It  may  be  difficult  to  explain  this  observation,  but  it  is  Hkely  that  even  a  small 
amount  of  food  or  mucus  in  the  stomach  will  be  forced  into  the  duodenum,  and  that 
when  it  passes  over  the  entrance  of  the  common  duct,  it  causes  a  contraction  of  the 
gall-bladder,  and  this  excites  the  pain. 

The  use  of  moist  heat  in  the  form  of  poultices  or  fomentations,  or  of  cold  by 
means  of  an  ice-bag,  gives  the  patient  great  comfort  and  is  undoubtedly  beneficial. 

Morphin  may  be  given  hypodermically  if  necessary,  but  so  long  as  neither  food 
nor  cathartics  are  given  by  mouth,  the  pain  usually  subsides  rapidly  and  perma- 
nentlv.  Nourishment  may  be  given  by  enema  not  oftener  than  once  in  four  hours, 
nor  in  larger  quantities  than  four  ounces  at  a  time.  I  prefer  for  this  purpose  an 
ounce  of  one  of  the  various  rehable  predigested  foods  mixed  with  three  ounces  of 
warm  normal  salt  solution.  Unless  the  acute  condition  is  complicated  with  a  me- 
chanical obstruction  of  the  intestines,  the.  patient's  chances  for  recovery  from  the 
acute  attack  are  far  better  without  than  with  an  operation. 

It  is  necessary  to  make  a  definite  distinction  between  intestinal  obstruction  due 
to  peritonitis  and  the  same  condition  due  to  a  mechanical  obstruction,  such  as  the 
impaction  of  a  gall-stone.  The  former  is  so  much  more  common  that  it  is  only 
very  seldom  that  the  latter  need  be  considered.  Mechanical  obstruction  due  to 
impaction  of  a  gall-stone  is  characterized  by  the  sudden  onset  of  symptoms  of  an 
acute  intestinal  obstruction,  without  the  inflammatory  symptoms  which  must  be 
present  if  it  was  due  to  a  peritonitis. 

When  the  patient  has  recovered  from  his  acute  attack,  the  further  treatment  may 
be  medical,  which  will  not  cure  him,  but  may  improve  his  condition  very  greatly; 
or  surgical,  which  is  likely  to  result  in  a  perfect  permanent  recovery. 

The  medical  treatment  must  consist  chiefly  in  the  use  of  large  quantities  of  water, 
preferably  taken  hot,  and  in  the  use  of  a  diet  fairly  free  from  sugar  and  starch. 

I  believe,  however,  that  the  greatest  benefit  comes  from  drinking  a  great  amount 
of  good  water  and  never  eating  quite  enough  to  satisfy  hunger,  and  from  taking 
vigorous  out-of-door  exercise,  such  as  horseback-riding,  walking,  or  rowing.  So- 
dium phosphate  in  dose  of  one  dram  or  more,  taken  in  a  large  goblet  of  hot  water, 
half  an  hour  before  each  meal,  and  pure  olive  oil  taken  in  dose  of  one-half  to  four 
ounces  at  bedtime,  seem  to  have  given  relief  to  patients  suffering  from  gall-stones. 
Many  patients  remain  free  from  severe  attacks  for  a  long  period  of  time  by  employ- 
ing these  remedies  together  with  proper  diet  and  exercise. 

Whether  relief  is  due  to  the  fact  that  in  this  manner  constipation  is  prevented 
and  ehmination  is  facilitated  by  the  large  drafts  of  hot  water,  or  whether  there  is 


TREATMENT.  293 

some  special  virtue  in  the  remedies,  it  is  difficult  to  say.  That  many  of  the  patients 
are  relieved  of  their  gall-stone  colics  upon  following  this  plan  of  treatment  there 
can  be  no  doubt.  It  is  plain,  however,  that  this  form  of  treatment  can  be  of  benefit 
only  to  a  limited  number  of  patients,  namely,  those  in  whom  there  is  no  impaction 
of  the  gall-stones  in  the  gall-bladder  or  in  the  common  or  cystic  duct,  and  which 
are  not  complicated  with  serious  lesions  of  any  part  of  the  mucous  membrane 
or  with  extensive  adhesions.  INIoreover,  these  patients  are  apt  to  have  recurrences 
with  one  or  more  of  the  complications  enumerated  above.  Aside  from  this,  there 
is  always  the  danger  of  carcinoma  as  a  result  of  the  long-continued  irritation. 

For  all  cases,  then,  which  cannot  be  relieved  in  this  manner  with  some  degree 
of  permanency,  and  for  those  who  are  unwilling  to  undergo  continuous  medical 
and  hygienic  treatment,  nothing  remains  but  the  removal  of  the  gall-stones  by  an 
operation. 

Preparation  of  Patient  for  Operation. — The  first  step  in  the  preparation  of  the 
patient  after  entering  the  hospital,  or  after  an  operation  has  been  decided  upon, 
is  once  more  to  make  a  thorough  examination  of  the  patient,  either  in  person  or, 
better  still,  by  an  equally  competent  associate.  This  examination  should  be  made 
independently  by  the  associate,  and  then  the  results  should  be  compared.  It  should 
be  made  in  a  systematic  way,  and  in  hospital  practice  at  a  stated  period,  so  that 
enough  time  will  be  allotted  to  make  it  thorough.  It  is  extremely  easy  to  form  care- 
less routine  habits  unless  one  constantly  follows  a  definite  scientific  plan. 

It  is  true  that  this  plan  increases  the  amount  of  labor  materially  and  that  it  is 
rare  that  any  new  facts  are  determined  by  the  second  examination,  but  it  is  just 
in  the  few  cases  that  it  proves  to  be  of  the  greatest  importance. 

In  this  systematic  examination  many  things  are  considered  which  may  not  have 
any  bearing  upon  any  given  case  in  question,  but  when  applied  to  all  the  cases  in 
practice,  each  point  is  of  considerable  importance. 

After  all  of  the  conditions  present  in  the  case  have  been  determined,  the  neces- 
sary preparations  for  the  operation  may  proceed. 

If  there  exists  a  serious  complicating  disease,  i.  e.,  if  the  heart,  lungs,  kidneys, 
or  blood  be  seriously  impaired,  it  is  well  to  overcome  this  fault  unless  it  is  directly 
the  result  of  a  condition  which  is  to  be  relieved  by  the  operation  itself  and  which 
will  probably  improve  much  more  rapidly  after  than  before  the  operation.  If  no 
vital  organ  is  seriously  impaired,  it  is  much  better  not  to  worry  the  patient  un- 
necessarily before  the  operation.  As  a  rule,  a  long-continued  preparation  leaves 
the  patient  in  a  less  favorable  condition  for  a  surgical  procedure  than  a  very  short 
and  simple  preparation,  which  serves  to  put  the  kidneys,  the  skin,  and  the  alimen- 
tary canal  in  a  condition  favorable  to  the  elimination  of  waste  products. 

Tliis  is  accomplished  by  giving  the  patient  two  ounces  of  castor  oil  twenty-four 
hours,  and  one  or  two  enemata  eight  and  twelve  hours,  before  the  operation.  Gastric 
lavage  is  performed  just  before  operating. 

During  the  twenty-four  hours  previous  to  the  operation  only  sterilized  liquids 
are  given  by  mouth,  together  with  an  abundance  of  hot  water. 


294  OPERATIONS    rPOX    THE    GALL-BLADDER,    BILE-DUCTS,    AXD    LIVER. 

Some  attention  should  be  given  to  the  condition  of  the  mouth.  In  most  patients 
it  is  well  to  have  the  teeth  cleansed  by  means  of  a  tooth-brush,  and  an  antisep- 
tic mouth-wash  used  every  four  hours,  and  oftener  in  cases  where  there  are  decayed 
teeth. 

In  very  obese  patients  it  is  a  good  plan  to  give  a  strict  diet  for  some  weeks  pre"vn- 
ous  to  the  operation.  This  should  contain  an  abundance  of  lean  beef  or  mutton, 
and  almost  no  starch,  sugar,  or  fat.  In  the  mean  time  the  patient  should  take  vigorous 
exercise,  and  the  abdominal  walls  should  be  massaged  systematically.  I  have 
many  times  reduced  the  weight  of  obese  patients  fifty  or  more  pounds,  and  in  one 
case  one  hundred  and  forty  pounds,  at  the  same  time  gready  increasing  the  patient's 
strength  and  comfort. 

In  cases  where  there  is  marked  jaundice,  calcium  chloride,  in  dose  of  one  dram, 
given  in  a  pint  of  hot  water  three  times  the  day  previous  to  the  operation,  seems 
to  be  valuable  in  increasing  the  coagulability  of  the  blood. 

In  many  patients  there  is  an  especially  tense  abdominal  wall,  which  may  refuse 
to  relax  even  after  the  administration  of  an  anesthetic.  In  these  cases  it  is  well  to 
administer  one-fourth  of  a  grain  of  morphin,  preferably  with  ywo  grain  of  atropin, 
h^'podermically  half  an  hour  before  the  operation. 

The  Field  of  Operation.— The  important  point  in  preparing  a  surface  for  opera- 
tion lies  in  the  thorough  washing  with  soap  and  water;  anything  that  is  done  beyond 
this  is  of  litde  importance  provided  the  washing  process  has  been  done  carefully 
and  thoroughly. 

In  mv  practice  the  steps  taken  to  prepare  the  field  of  operation  are  as  follows: 

1.  Thorough  scrubbing  T^Hth  soap  and  warm  water,  with  a  soft  brush. 

2.  Wasliing  the  surface  with  a  piece  of  aseptic  gauze  "v^-ith  fresh  water,  because 
the  epithelial  cells  which  have  been  loosened  Ijy  the  brush  are  easily  removed  in  this 
manner. 

3.  Soaping  and  sha^'ing  the  field  of  operation. 

4.  Washing  again  with  aseptic  gauze  and  sterile  water. 

5.  Washing  the  surface  with  alcohol. 

6.  Washing  with  a  solution  of  corrosive  sublimate,  one  part  in  two  thousand. 
In  hospitals  where  many  operations  are  performed  on  the  same  day,  so  that  the 

time  spent  on  each  case  immediately  preceding  an  operation  is  of  importance, 
it  may  be  well  to  prepare  the  field  of  operation  the  day  before,  and  then  protect 
the  surface  from  reinfection  during  the  interval  by  appMng  a  sterile  gauze  dressing. 
At  the  time  of  operation  this  dressingjs  removed  and  the  field  of  operation  sponged 
with  sterile  gauze  and  alcohol. 

This  is  done  simply  for  convenience  and  not  because  it  is  better  than  to  prepare 
the  field  of  operation  immediately  before  beginning  to  operate.  For  months  at  a 
time  I  have  followed  the  latter  plan  witliont  having  a  single  wound  infected,  and 
other  surgeons  have  had  the  same  experience. 

Operation. — In  operations  upon  the  gall-bladder,  and  especially  those  upon 
the  bile-ducts,  considerable  advantage  can  be  gained  by  placing  a  sand-bag  20  to 


TREATMENT.  295 

30  cm.  in  diameter  under  the  patient's  back,  at  or  a  little  above  the  level  of  the  liver. 
This  will  cause  the  liver  to  present  in  the  wound  and  afford  easy  access  to  the  cystic 
and  common  ducts.     This  position  is  illustrated  in  Fig.  543. 

For  all  gall-bladder  operations  a  straight  incision  made  through  the  right  rectus 
muscle,  near  its  outer  border,  is  undoubtedly  the  best,  primarily.  The  upper  end 
of  the  incision  starts  at  the  costal  margin  and  extends  downward.  The  incision  is 
first  carried  through  the  skin,  superficial  and  deep  fascias,  down  to  the  muscle-fibers. 
These  should  be  separated  longitudinally,  by  means  of  a  blunt  instrument  like 
the  handle  of  a  scalpel,  so  that  none  of  the  fibers  are  cut.  The  incision  is  com- 
pleted by  carrying  it  through  the  transversalis  fascia  and  the  peritoneum.  The 
incision  should  be  long  enough  to  admit  the  entire  hand,  as  advised  by  Maurice 


'•■V         hdrd  piUow 
Fig.  543. — Mayo  Robson's  Position  of  Patient  for  Gall-bladder  and  Gall-duct  Operation. 

Richardson.  This  is  important  because  the  next  step  must  consist  in  a  careful 
palpation  of  the  gall-bladder,  the  cystic,  the  hepatic,  and  the  common  ducts.  This 
cannot  be  done  thoroughly  without  introducing  the  entire  hand. 

The  pancreas  and  the  duodenum  and  the  pylorus  should  be  examined  at  the 
same  time. 

The  various  incisions  used  in  operations  upon  the  gall-tract  are  illustratetl  in 
Fig.  544. 

Should  it  be  found  that  more  room  is  needed  than  the  rectus  incision  gives,  it 
may  be  obtained  by  carrying  the  upper  end  of  the  incision  upward  and  inward, 
cutting  the  rectus  fibers  about  one  inch  from  the  costal  margin,  which  virtually 
converts  our  primary  rectus  incision  into  one  first  suggested  by  Mayo  Robson.  Or 
this  rectus  incision  may  be  converted  into  the  "S  "-shaped  incision  as  devised  by 


296 


OPERATIONS   UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 


Bevan.     It  is  rare,  though,  that  there  will  be  need  for  any  other  than  the  straight 
rectus  incision. 

Cholecystotomy. — The  simplest  operation  upon  the  gall-bladder  is  chole- 
cystotomy. 

The  simplest  form  of  this  operation,  suggested  by  Meredith  more  than  twenty 
years  ago,  consisting  in  the  removal  of  the  gall-stones  and  the  immediate  suturing 
of  the  gall-bladder  with  Lembert's  sutures,  has  been  almost  entirely  abandoned, 
except  in  cases  in  which  gall-stones  are  incidentally  discovered  in  a  practically  nor- 
mal gall-bladder  during  an 
operation    for    some    other 
intra-abdominal  condition. 

There  are  a  few  sur- 
geons who  still  favor  this  op- 
eration for  all  cases  of  gall- 
stones without  a  marked 
degree  of  cholecystitis; 
among  them,  no  less  an 
authority  than  Kocher. 

In  every  step  except  the 
last  this  operation  corre- 
sponds to  that  of  cholecys- 
tostomy,  consequently  the 
two  operations  will  be  des- 
cribed together  up  to  this 
point.  Both  of  these  opera- 
tions are  performed  for  the 
purpose  of  removing  stones 
from  the  gall-bladder,  and 
in  some  cases  from  the  cystic 
duct. 

Colecystotomy  is  further 
performed  for  the  purpose 
of  establishing  drainage  of 
the  gall-bladder,  which  is 
useful  not  only  in  relieving 
irritation  of  the  gall-bladder  and  biliary  ducts,  but  also  indirectly,  it  seems,  to  drain 
the  liver  and  the  pancreas,  and  as  a  result  of  this  drainage  these  organs,  when 
generally  enlarged  as  a  result  of  chronic  inflammation  or  irritation  due  to  faulty 
drainage,  will  decrease  in  size  very  rapidly. 

It  is  consequently  important  to  determine  these  conditions  before  deciding  upon 
the  operation  to  be  chosen  in  any  given  case.  After  making  the  incision,  the  hand 
is  introduced  into  the  abdominal  cavity  and  the  gall-bladder  is  palpated  between 


Fig.  544. — Incision  fob  Gall-bladder  and  Gall-duct  Operation. 

No.    1,    Mayo    Robson's    incision;    No.    2,    Bevan's    incision;    No.    i 

Koclier's  incision. 


TREATMENT. 


297 


the  finger  and  thumb.     It  is  then  followed  downward  and  inward  and  the  cystic, 
the  hepatic,  and  the  common  ducts  are  palpated  in  succession. 

Occasionally  the  gall-bladder  may  be  so  tense  that  nothing  can  be  determined 
concerning  the  character  of  its  contents,  except  that  whatever  the  gall-bladder  may 
contain  it  is  impossible  for  this  substance  to  pass  on  freely  into  the  duodenum,  and 
this,  in  itself,  is  the  strongest  indication  for  a  cholecystotomy.  If  this  condition  is 
found,  or  if  gall-stones  are  found  in  the  gall-bladder  or 
the  cystic  duct,  but  none  in  the  hepatic  or  common 
ducts,  this  operation  is  plainly  indicated. 

The  examination  may  have  revealed  more  or  less 
extensive  recent  or  old  adhesions  between  the  gall- 
bladder and  the  surrounding  organs. 

These  adhesions  may  include  the  liver,  the  omentum, 
the  transverse  colon,  the  duodenum,  or  the  stomach, 
and  in  some  instances  even  the  right  kidney,  or  they 
may  include  any  two  or  more  of  these  organs. 

If  they  are  recent,  or  if  they  distort  one  or  more  of 
these  organs,  it  is  well  to  loosen  or  to  ligate  and  cut  these 
adhesions.  If  they  have  existed  for  a  long  period  of 
time  without  apparently  doing  any  harm,  it  is  better 
to  leave  them  undisturbed.  It  must,  however,  be  borne 
in  mind  that  undoubtedly  the  adhesions  of  the  gall- 
bladder frequently  draw  this  down  and  cause  it  to  be- 
come sacculated  so  that  it  will  contain  residual  bile, 
and  that  this  in  turn  favors  infection  of  this  fluid,  and 
thus  the  formation  of  gall-stones.  It  is  consequently 
important  to  remove  any  adhesions  which  seem  to  show 
a  tendency  to  cause  sacculation  of  the  gall-bladder. 

This  having  been  accomplished,  soft  gauze  pads 
moistened  with  warm  normal  salt  solution  are  placed 
about  the  gall-bladder  after  the  latter  has  been  grasped 
at  its  most  prominent  point  with  one  or  two  pairs  of 
forceps. 

This  act  of  packing  away  the  remaining  portion  of 
the  peritoneal  cavity  should  be  done  with  the  greatest 
care,  to  prevent  soiling  during  the  succeeding  steps  of 
the  operation. 

A  trocar  is  then  plunged  into  the  gall-bladder  to 
drain  away  the  bile,  or  pus,  or  mucus,  as  the  case  may  be,  contained  in  the  ca\ity. 
The  trocar  shown  in  Fig.  545  is  undoubtedly  most  convenient,  because  with  it  the 
gall-bladder  can  be  emptied  perfectly  without  the  slightest  danger  of  soiling  any  of 
the  surrounding  tissues. 

Should  the  gall-bladder  be  contracted  because  of  the  long-continued  destructive 


o 


Fig.  545. — Trocar  for  As- 
pirating THE  Gall-blad- 
der. 


298  OPERATIONS   UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

inflammation  which  distinguishes  old  gall-stone  cases  from  obstruction  due  to 
malignant  growths  according  to  the  law  of  Courvoisier,  it  might  not  be  neces- 
sary to  make  use  of  the  trocar,  because  there  will  be  no  bile  in  what  is  left  of 
the  gall-bladder.  In  these  cases  the  most  prominent  portion  of  the  gall-bladder 
is  grasped  by  the  forceps  and  an  incision  made  through  the  highest  portion, 
which  is  also  the  next  step  after  the  fluid  has  been  aspirated  in  the  other  class 
of  cases. 

If  there  is  still  a  little  fluid  present,  this  is  absorbed  by  lightly  tamponing  the 
cavity  of  the  gall-bladder  with  a  narrow  strip  of  aseptic  gauze  and  withdrawing  it. 
This  can  be  repeated  a  number  of  times.  A  blunt  gall-stone  scoop  is  now  introduced 
and  gently  withdrawn,  bringing  out  as  many  of  the  stones  as  can  be  reached  in  this 

manner     (Fig.     546). 
Then,  while  an  assist- 
ant holds  up  the  gall- 
^  „  ^  bladder  by  hemostatic 

Fig.    546. — Gall-stone    Spoon    for    Removing    Stones    from   the    Gall-  *' 

BLADDER.  forccps  attachcd  to  the 

edge  of  the  wound, 
the  surgeon's  hand  is  again  introduced  into  the  abdominal  cavity,  and  the  gall- 
bladder and  all  its  ducts  are  once  more  carefully  palpated. 

If  there  are  still  stones  present,  these  can  be  removed  with  the  scoop,  guided  by 
the  hand  in  the  abdominal  cavity.  If  there  are  stones  in  the  cystic  duct,  these  can 
frequently  be  forced  back  into  the  gall-bladder  by  a  gentle  milking  motion  between 
the  forefinger  and  thumb.  Occasionally  this  can  be  aided  by  the  use  of  a  small 
curet  guided  by  the  other  hand. 

In  a  few  instances  it  has  been  possible  to  transfer  to  the  gall-bladder  not  only 
stones  in  the  cystic  duct,  but  even  those  in  the  common  duct  and  hepatic  duct,  in  this 
manner.  Great  caution  must,  however,  be  practised,  because  less  injury  is  done 
to  the  patient  by  making  an  incision 
into  these  ducts  than  by  severe  manip- 
ulation in  the  attempt  at  removing 
stones,  especially  if  these  are  im- 
movable   as    the    result    of    impaction.  Fig.  547.— Gall-stone  Forceps  (Moynihan). 

So  far  the  steps  of  the  operation  are 
agreed  upon  practically  by  every  one  who  has  a  large  experience  in  the  treatment  of 
these  cases.     From  this  point  on,  authorities  of  equal  ability  vary  in  the  details  of 
their  technic. 

I  have  used  at  various  times  most  of  the  methods  which  have  been  recommended, 
thinking  that  one  might  be  indicated  under  certain  conditions,  while  another  might 
be  more  suitable  for  a  shghtly  different  condition,  but  I  am  convinced  that  the  special 
benefits  from  these  various  operations  are  entirely  imaginary. 

In  more  than  three  hundred  successive  cases  I  have  employed  the  following 
simple  technic,  after  being  satisfied  that  ah  the  stones  had  been  removed. 

1.  The  gall-bladder  is  carefully  but  gently  and  loosely  tamponed  with  a  long 
strip  of  dry  gauze.     This  serves  to  prevent  hemorrhage  from  the  mucous  lining  of 


TREATMENT. 


299 


the  gall-bladder,  which  is  frequently  severely  congested,  and  often  covered  with 
bleeding  granulations. 

2.  The  transversalis  fascia  and  the  peritoneum  of  the  upper  angle  of  the  wound 
are  then  sutured  to  the  gall-bladder,  1  to  2  cm.  from  the  edge  of  the  opening 
into  it. 

Fig.  548  shows  the  gall-bladder  with  the  forceps  upon  its  edge  and  drawn  out 
through  the  wound,  and  a  catgut  stitch  being  placed  which  attaches  the  gall-bladder 
to  the  peritoneum.  The  stitch  in  the  gall-bladder  passes  down  to,  but  not  through, 
the  mucous  lining  of  the  gall-bladder. 


Fig.   548. — Shows  Gall-bladder  with  Forceps  upon  its  Edge  and  being  Sutured  to  the  Peritoneum. 


If  the  gall-bladder  is  small  and  shrunken,  the  peritoneum  and  the  transversalis 
fascia  are  brought  down  to  it  at  one  or  two  points,  and  a  piece  of  gauze  is  carried 
down  to  the  gall-bladder,  and  between  the  gauze  and  the  surrounding  tissue  a  piece 
of  rubber  tissue  is  placed.  Attaching  the  gall-bladder  in  this  manner  facilitates 
drainage  and  prevents  the  gall-bladder  later  on  from  becoming  sacculated. 

3.  The  incision  above  and  below  the  gauze  drain  is  closed  after  the  general 
plan  illustrated  in  Fig.  549,  showing  the  closure  of  a  laparotomy  wound  in  the 


300 


OPEEATIONS    UPON   THE    GALL-:BLADDER,    BILE-DUCTS,    AND    LIVER. 


median  line.     This  differs  from  the  closure  of  the  gall-bladder  incision  through  the 
right  rectus  abdominis  muscle,  in  that  the  second  row  of  catgut  sutures  unites  the 


Fig.  549. — Cross-section  of  Abdominal  Wall  Showing  Closure  or  Wound  after  a  Median  Incision. 
a,  Skin;    b,    subcutaneous   fat;    c,    aponeurosis   of  external   oblique   abdominal   muscle;    d,    aponeurosis   of 
internal  abdominal  muscle  divided  into  inner  and   outer  layer;    e,  connective   tissue;   f,   transversalis  fascia  and 
peritoneum;  g,  line  of  suture;    i,  rectus  abdominis  muscle. 

two  abdominis  muscles,  instead  of  the  two  split  edges  of  the  right  rectus  abdominis 
muscle.  Two  of  the  fine  silkworm-gut  stitches  are  passed  through  all  the  tissues 
down  to  but  not  through  the  transversalis  fascia;  these  are 
left  untied  until  the  following  rows  of  catgut  sutures  have 
been  applied  in  order  to  prevent  the  formation  of  a  ventral 
hernia,  by  carefully  approximating  the  following  layers:  (a) 
peritoneum  and  transversaHs  fascia;  (b)  rectus  abdominis 
muscle;  (c)  aponeurosis  of  the  external  and  the  outer  layer 
of  the  internal  oblique  muscle  passing  in  front  of  the  rectus 
abdominis  muscle  at  this  point;   (d)  the  skin. 

These  layers  are  all  approximated  by  suturing  with 
unchromicized  catgut,  except  the  skin,  for  which  horsehair 
is  used.  The  closure  of  the  wound  is  completed  by  tying 
the  silkworm-gut  sutures. 

4.  Some  rubber  tissue  is  now  stuffed  down  to  the  gall- 
bladder, between  the  edges  of  the  abdominal  wall  and  the 
gauze  tampon,  to  facilitate  its  removal.  This  is  done  about 
the  fifth  day,  when  a  rubber  drainage-tube  is  inserted  into 
the  gall-bladder. 

The  other  methods  which  seem  equally  satisfactory  consist 
in  using,  instead  of  a  gauze  tampon,  a  simple  rubber  tube,  or  a  spht  rubber  tube 
filled  with  a  strip  of  gauze,  or  a  cigarette  drain.  Any  one  of  these  may  be  fast- 
ened in  the  gall-bladder  by  placing  a  pursestring  suture  around  the  opening,  invert- 


Fia.     550. — Jacobs'     Re- 
tention Catheter. 


TREATMENT. 


301 


ing  the  edges,  and  then  drawing  the  pursestring  just  sufficiently  tight  to  prevent 
leakage. 

Still  another  method  consists  in  applying  one  of  these  various  forms  of  drainage, 
and  then  simply  permitting  this  to  project  from  the  upper  angle  of  the  abdominal 
wound  without  suturing  the  gall-bladder  to  the  parietal  peritoneum.  Personally, 
I  have  never  been  favorably  impressed  by  this  method. 


Fig.  551. 
L,  Liver;   G.  hi.,  gall-bladder;  D,  duodenum. 


Cholecystotomy. — Going  back  to  the  point  at  which  we  had  arrived  after 
removing  all  of  the  gall-stones,  the  opening  in  the  gall-bladder  may  be  closed  by 
slightly  inverting  the  edges  and  applying  one  row  of  fine  continuous  catgut  suture, 
including  all  of  the  layers,  a  second  row  of  continuous  I.emljert  sutures  over  this, 
also  of  fine  catgut,  dropping  the  gall-bladder,  and  closing  the  abdominal  wall; 


302 


OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 


or  a  small  iodoform  gauze  wick  may  be  carried  down  to  the  suture  row  and  passed 
out  through  the  upper  angle  of  the  wound. 

It  has  always  seemed  to  me  that  much  benefit  in  gall-bladder  cases  comes  from 
the  drainage  of  the  gall-bladder  after  operation,  and  that  consequently  cholecys- 
totomy  is  practically  never  indicated. 

Continued  Drainage  of  the  Gall-bladder. — In  case  it  seems  wise  to  continue 
the  drainage  of  the  gall-bladder  for  a  considerable  period  the  patient  can  be  made 
more  comfortable  by  inserting  a  Jacobs  retention  catheter  of  proper  size  into  the 
gall-bladder,  attaching  a  glass  tube  to  the  distal  end  of  this  catheter,  and  tying  a 


Fig.  552. — Cutting  of  Peritoneal  Fold  between  Gall-bladder  and  Liver  after  Cystic  Duct  has  been 

Clamped  and  Severed. 
L,  Liver;    G.  bl.,  gall-bladder;    c.  d.,  cystic  duct;    D,  duodenum. 

soft-rubber  bag  to  this  in  order  to  collect  the  bile.  Whenever  it  seems  proper  to 
interrupt  this  drainage,  the  opening  will  close  spontaneously  upon  withdrawing 
the  catheter. 

Cholecystectomy. — This  operation  is  indicated  in  cases  in  which  there  is 
a  permanent  obstruction  of  the  cystic  duct,  which  is  usually  due  to  a  cicatricial  con- 
traction of  an  ulcer,  most  commonly  caused  by  the  impaction  of  a  stone. 

It  may  also  be  due  to  the  formation  of  a  valve  in  the  neck  of  the  gall-bladder  at 
its  entrance  into  the  cystic  duct.  Occasionally  such  a  valve  w411  permit  the  free 
flow  of  bile  into  the  gall-bladder,  but  not  in  the  opposite  direction. 

Cholecystectomy  should  be  performed  in  early  cases  of  primary  carcinoma  of 
the  gall-bladder.     In  some  cases  in  which  the  gall-bladder  has  been  badly  diseased 


TREATxMENT. 


303 


for  some  time,  the  disease  being  limited  to  the  organ  alone,  and  circumstances  per- 
mit of  easy  removal,  cholecystectomy  will  be  the  operation  of  choice. 

The  removal  of  the  gall-bladder  is  usually  not  a  difficult  matter  if  it  is  approached 
from  the  right  direction.     The  following  simple  steps  should  be  followed: 

1.  The  same  incision  as  in  cholecystostomy  should  be  made.  Occasionally 
if   there   are   many  adhesions,  so    that  it  is  difficult  to   reach  the  lower  end    of 


±F.:B'^<^ei'^ 


Fig.  553. 
L,  Liver;    G.  hi.,  gall-bladder;    S,  stone  in  cystic  duct;    D,  duodenum. 


the  gall-bladder,  the  incision  may  be  lengthened,  according  to  the  plan  advised 
by  Bevan,  by  extending  the  upper  end  of  the  incision  inward  and  the  lower  end  out- 
ward, or  it  may  be  extended  according  to  Mayo  Robson,  between  the  edge  of  the 
costal  cartilages  and  the  lower  end  of  the  sternum,  in  order  that  the  liver  with  the 
gall-bladder  may  be  inverted  upward. 

2.   Two  pairs  of  hemostatic  forceps  are  then  applied,  one  directly  to  the  cystic 


304  OPERATIONS    UPOX   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

duct,  grasping  at  the  same  time  the  cystic  artery  which  supphes  the  gall-bladder; 
the  second  pair  is  applied  to  the  neck  of  the  gall-bladder  at  a  distance  of  1  cm.  from 
the  other.  Fig.  551  shows  the  two  pairs  of  forceps  in  place.  The  neck  of  the 
gall-bladder  is  divided  between  them. 

3.  An  incision  is  now  made  along  the  sides  of  the  gall-bladder,  through  its  peri- 
toneal covering,  about  1  cm.  from  its  attachment  to  the  liver,  and  then  the  organ 
can  be  enucleated  without  difficulty,  as  shown  in  Figs.  552  and  553. 

If  there  is  any  considerable  amount  of  hemorrhage  from  the  surface,  a  hot  tam- 
pon of  gauze  against  the  surface  for  five  minutes  will  control  the  oozing  at  once, 


Fig.  554. — LTnder  Surface  of  Liver  after  Gall-bladder  has  been  Removed. 
L,  Liver;   p.  g.  hi.,  peritoneum  of  gall-bladder;    D,  duodenum. 

and  then  the  raw  surface  can  be  closed  by  suturing  together  the  two  peritoneal  folds 
with  catgut  as  shown  in  Figs.  553  and  555. 

Fig.  554  shows  the  under  surface  of  the  liver  after  the  gall-bladder  and  the  cystic 
duct  have  been  removed.  Fig.  555  shows  where  the  two  edges  of  the  peritoneum 
have  been  sutured,  covering  over  the  raw  surface  made  by  excising  the  gall-bladder. 
Fig.  556  shows  the  rubber  drain  placed  in  the  hepatic  duct,  which  is  pulled  down- 
ward for  sake  of  illustration. 

4.  Disposition  of  the  stump:  If  drainage  is  not  desired,  a  ligature  can  be  placed 
about  the  stump  of  the  cystic  duct,  including  the  cystic  artery,  as  shown  in  Fig.  553. 

If  the  necessity  for  drainage  is  doubtful,  the  artery  forceps  may  be  left  in  place, 


TREATMENT. 


305 


and  may  be  surrounded  by  gauze  and  rubber  protective,  and  permitted  to  pass  out 
of  the  upper  angle  of  the  wound.  This  may  be  loosened  after  thirty-six  hours,  or 
sooner  if  it  should  become  apparent  that  drainage  is  desired. 

It  is  well  in  these  cases  to  insert  a  drainage-tube  to  a  point  just  below  the  stump 
for  the  purpose  of  providing  for  an  emergency.  It  is  immaterial  what  form  of 
drainage-tube  is  chosen.  In  case  drainage  of  the  cystic  duct  is  desired,  the  cystic 
artery  is  caught  separately  at  the  end  of  the  stump  and  ligated  and  a  small  rubber 
drainage-tube  is  introduced  directly  into  the  common  duct  through  the  cystic  duct. 

Fio-.  557  shows  a  drainage-tube  which  is  most  useful  in  these  cases.  A  small 
rubber  drainage-tube  (a)  is  drawn  through  a  larger  tube  (b),  the  perforated  end  (c) 


Fig.  555. — Showing  two  Edges  of  Peritoneum  of  Gall-bladder  Sutured  after  Excision  of  Gall-bladder. 
L,  Liver;    p.  g.  hi.,  peritcneum  of  gall-bladder;    D,  duodenum;    e,  ligated  cystic  duct. 

is  introduced  into  the  cystic  duct,  and  it  is  held  in  place  by  one  or  more  catgut 
sutures,  which  pass  through  the  outer  tube  (h)  but  do  not  touch  the  inner  tube.  By 
the  time  the  catgut  is  absorbed,  it  is  time  to  withdraw  the  drainage-tube. 

The  abdominal  wound  is  closed  as  in  the  previous  operation,  and  the  tissues 
are  prevented  from  adhering  to  the  gauze  by  the  interposition  of  the  rubber  tissue. 

Occasionally  the  surface  of  a  gall-bladder  in  which  there  is  positive  indication 
for  cholecystectomy  is  so  strongly  adherent  that  it  may  be  difficult  or  impossible  to 
perform  the  operation  just  described. 

For  the  relief  of  these  cases  W.  J.  Mayo  has  advised  the  following  operation, 
which  I  have  performed  with  perfectly  satisfactory  results,. both  as  regards  immedi- 
ate and  late  conditions. 
VOL.  11—20 


306  OPERATIONS    UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

The  operation  consists  in  making  a  circular  incision  through  the  tissues  of  the 
gall-bladder  down  to  but  not  through  the  mucous  membrane.  The  latter  is  then 
dissected  down  to  the  cystic  duct,  and  the  operation  is  completed  as  in  ordinary 
cholecystectomy. 

Choledochotomy. — In  operating  on  the  common  duct  a  sand-bag  is  always 
placed  under  the  back  opposite  the  liver,  as  ad\'ised  by  Mayo  Robson.  The  usual 
straight  incision  is  made  through  the  right  rectus  abdominis  muscle.  If  it  is  found 
necessary  to  open  the  common  duct  and  more  room  is  desired,  the  incision  is  carried 
upward  and  inward  between  the  right  costal  margin  and  the  ensiform  cartilage. 


Fig.  556. — Shows  Rubber  Drain  Placed  in  the  Hepatic  Duct,  which  is  pulled  Downward  for  Sake  of 

Illustration. 
L,  Liver;    p.  g.  hi.,  peritoneum  of  gall-bladder;    h.d,  hepatic  duct;    c.d,  cystic  duct. 

Now,  by  Hfting  the  lower  edge  of  the  liver  out  of  the  wound,  it  will  be  found  that  the 
gall-bladder  and  the  cystic  and  common  ducts  will  be  brought  into  plain  view.  The 
liver  is  held  in  this  position  by  an  assistant,  who  grasps  the  lower  edge  of  the  liver 
with  his  fingers  covered  with  a  piece  of  dry  gauze.  When  the  liver  is  held  in  this 
position,  it  will  be  found  that  the  cystic  and  common  ducts  make  an  almost  straight 
passage  from  the  neck  of  the  gall-bladder  to  the  entrance  into  the  duodenum. 

If  there  are  adhesions  about  the  ducts,  these  are  separated,  a  sponge  is  placed 
in  the  kidney  pouch,  and  the  entire  field  of  operation  is  protected  by  sterile  pads. 

The  stone  is  located  and  grasped  between  the  thumb  and  finger  of  the  left  hand. 
While  the  stone  is  held  in  this  position,  two  catgut  sutures  are  placed  in  the  side  of 


TREATMENT. 


307 


the  common  duct  directly  over  the  stone.  These  sutures  are  left  long.  A  little  ten- 
sion is  made  upon  the  sutures,  then  the  duct  is  opened  by  making  a  longitudinal 
incision  between  the  two  sutures  directly  over  the  stone. 

Fig.  558  illustrates  a  stone  in  the  common  duct,  and  a  catgut  suture  applied  to 
each  side  of  the  proposed  incision,  and  the  incision  made  directly  over  the  stone. 

After  all  obvious  stones  have  been  removed,  the  finger  should 
be  passed  into  the  duct  to  detect  any  stones  that  may  be  above 
or  below  the  incision. 

Any  sand  or  thick  bile  is  removed  by  packing  strips  of  gauze 
into  the  duct  in  the  manner  described  in  sponging  out  the  gall- 
bladder.    When  the  duct  is  clear,  the  incision  in  it  may  be 
closed  by  suture  or  may  be  drained.     If  there  is  not  much  evi- 
dence of  infection  of  the  common  duct,  and  the  gall-bladder 
looks  healthy  and  the  cystic  duct  is  patent,  the 
wound  in  the  common  duct  can  be  closed  with 
safety,  leaving  drainage  of  the  bile  through  the 
gall-bladder  only.     The  incision  in  the  duct  is  closed  by  first 
approximating  the  edges  with  a  fine  continuous  catgut  stitch, 
and  over  this  a  few  Lembert  stitches  of  silk.     A  cigarette 
drain  is  placed  down  to  the  common  duct  and  brought  up  out 
of  the  incision  by  the  side  of  the  gall-bladder  drain. 

The  majority  of  the  cases  require  drainage  of  the  common 
duct,  especially  in  those  where  the  head  of  the  pancreas  is 
enlarged  from  chronic  pancreatitis. 

A  double  drainage-tube,  as  shown  in  Fig.  557,  is  inserted 
into  the  common  duct  and  carried  upward  toward  the  hepatic 
duct.  The  two  catgut  sutures  which  were  placed  in  the  sides 
of  the  duct  as  guides  are  now  utilized  to  fasten  the  drainage- 
tube  in  place,  which  is  done  by  passing  the  sutures  through  the 
outer  rubber  tube  and  tying.     These  sutures  are  still  left  long. 

A  piece  of  iodoform  gauze  is  packed  around  the  tube  and 
brought  up  out  of  the  wound  by  the  side  of  the  drainage-tube  to 
further  protect  the  peritoneal  cavity.  These  same  sutures  are 
now  passed  through  the  gauze  and  tied  so  that  there  can  be  no 
displacement  of  the  gauze  should  the  patient  vomit  after  the 
operation. 

The  operation  is  completed  by  closing  the  wound  in  the 
usual  manner. 

Cholecystenterostomy. — This  operation  is  indicated  in  cases  in  which  there 
is  a  permanent  obstruction  between  the  entrance  of  the  hepatic  duct  into  the  com- 
mon duct  and  the  opening  of  the  latter  into  the  duodenum. 

The  entire  alimentary  canal  should  be  thoroughly  emptied  by  the  administration 
of  two  large  doses  of  castor  oil,  forty-eight  and  twenty-four  hours  before  the  opera- 


FiG.  557. — Double 
Drainage-tube  used 
FOR  Draining  Cystic 
OR  Common  Ducts. 


308  OPERATIONS   UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

tion.  A  careful  anastomosis  from  1  to  2  cm.  in  length  should  be  made  between  the 
gall-bladder  and  the  duodenum  by  any  one  of  the  various  methods  employed  in 
making  intestinal  anastomosis  with  needle  and  thread.  If  anastomosis  with  the 
duodenum  is  difficult,  the  jejunum,  ileum,  or  the  hepatic  flexure  of  the  colon  may  be 


Fig.  558. — Shows  Stone  in  Common  Duct  and  a  Catgut  Suture  Placed  to  Each  Side  of  the  Proposed 

Incision,    and    the    Incision    made    Directly    on    the    Stone 

L,  Liver;    G.bl.,  gall-bladder;   D,  duodenum. 

used.     If  a  mechanical  device  is  employed,  the  small  Murphy  button  should  be 
chosen,  but  the  suture  seems  to  be  a  superior  method. 

After-treatment. — When  the  operation  is  completed,  a  dry  sterile  gauze  dressing 
is  applied  and  held  in  place  by  a  snug  abdominal  bandage,  so  that  if  vomiting  should 
occur,  the  wound  will  receive  some  support  from  the  bandage. 


ABSCESS    OF   THE    LIVER.  309 

No  water  is  allowed  by  mouth  until  the  ether  sickness  and  the  nausea  are  over. 
If  the  thirst  is  great,  the  mouth  may  be  flushed  frequently  with  water  and  an  enema 
of  a  pint  of  salt  solution  may  be  given.  If  the  pain  is  severe,  morphin  in  doses  of 
^  to  J  of  a  grain  may  be  given  hypodermically. 

Four  to  eight  ounces  of  normal  salt  solution  are  given  by  enema  every  four 
hours  during  the  first  day.  Then  nourishing  enemata  in  the  form  of  one  ounce  of 
some  concentrated  liquid  predigested  food,  with  four  ounces  of  normal  salt  solution 
are  administered  every  four  hours  for  two  or  three  days. 

As  soon  as  the  nausea  from  the  anesthetic  is  over,  small  quantities  of  water  are 
given  by  mouth,  and  on  the  third  or  fourth  day  beef-tea  or  broth,  increasing  the  diet 
slowly  from  this  time  on. 

The  wound  is  dressed  daily  with  dry  sterile  gauze,  and  on  the  fourth  day  the 
gauze  is  removed  from  the  gall-bladder  and  a  rubber  tube  substituted,  which  in 
ordinary  cases  is  removed  at  the  end  of  a  week  or  ten  days,  and  the  wound  allowed 
to  close.  In  cases  accompanied  with  pancreatitis  or  a  marked  cholangitis  the  drain- 
age is  continued  for  a  period  of  from  two  to  four  weeks.  The  stitches  are  removed 
on  the  twelfth  day  and  the  patient  is  allowed  to  get  up  at  the  end  of  from  fourteen 
to  eighteen  days. 

The  Liver, 
abscess  of  the  liver. 

Dysentery  is  by  far  the  most  frequent  cause  of  abscess  of  the  liver^  (524  out  of  699 
cases,  Edwards  and  Waterman). 

The  condition  is  very  common  in  the  tropical  countries,  where  various  inflam- 
matory conditions  of  the  bowels  produce  a  thrombophlebitis  of  the  mesenteric 
vein;  the  clots  decomposing  become  dislodged  and  carry  the  infection  through  the 
branches  of  the  portal  vein,  producing  foci  of  suppuration.  In  hot  climates  they 
are  known  as  tropical  abscesses.  The  aTncebcB  dysenteries  have  frequently  been 
found  in  the  pus  from  these  lesions. 

Liver  abscess,  besides  occurring  during  the  course  of  dysentery,  may  be  due  to 
gall-stones,  typhoid  fever,  intestinal  ulcers,  inflammation  in  the  region  of  the 
portal  vein,  trauma,  and  syphilis;  it  may  also  be  a  complication  of  suppurative 
appendicitis.     Liver  abscess  has  resulted  also  from  actinomycosis.^ 

Symptoms. — The  most  constant  symptoms  as  observed  by  Johnston^  are: 
(1)  A  history  in  which  dysentery  and  chills  appear.  (2)  Pronounced  general 
malaise.  (3)  Pain  and  tenderness  over  liver.  (4)  Enlargement  of  the  liver. 
(5)  Hectic  sweats  and  rigors.  (6)  Right  lateral  posture.  (7)  Irregular  tempera- 
ture, running  from  96.5°  to  103.5°  F.  (8)  Progressive  emaciation.  (9)  Gastric 
disturbances. 

^  Fowler,  George  Ryerson:   "A  Treatise  on  Surgery,"  1906,  ii,  43. 
2  "International  Textbook  of  Surgery,"  Phila.,  1902,  ii,  450. 

'  Johnston,  George  Ben:  "Contribution  to  the  Surgery  of  Hepatic  Abscess,"  Ann.  Surgery, 
1897,  xxvi,  424. 


310  OPERATIONS   UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

Pain  in  the  region  of  the  liver  is  usually  an  early  and  prominent  symptom.  The 
pain  often  follows  the  course  of  the  phrenic  and  the  fourth  cervical  nerves  and  radiates 
toward  the  right  shoulder.  It  is  usually  constant  from  the  onset.  By  carefully 
noting  the  exact  limits  of  the  pain  and  tenderness,  the  abscess  may  often  be  located. 
Pain  is  always  increased  by  digital  pressure. 

Enlargement  of  the  liver  is  perhaps  the  most  invariable  objective  symptom,  and 
usually  causes  a  bulging  of  the  right  hypochondrium.  The  enlargement  may  take 
place  in  any  direction.  The  expansion  takes  the  course  of  least  resistance  and 
may  be  the  means  of  determining  the  seat  of  the  abscess. 

Prognosis. — The  prognosis  is  unfavorable,  especially  in  cases  of  multiple  ab- 
scess. The  patient  may  succumb  to  the  primary  infectious  disease,  or  to  pyemia 
or  sepsis,  or  the  abscess  may  rupture  into  the  peritoneal  cavity,  causing  a  septic 
peritonitis,  or  it  may  rupture  into  the  pleural  cavity,  resulting  in  septic  pneumonia. 

Treatment. — The  treatment  is  operative.  The  liver  must  be  reached  by  cross- 
ing either  the  pleura  or  the  peritoneum,  and  the  route  must  be  chosen  according  to 
the  location  of  the  abscess.  If  there  is  reason  to  believe  that  the  abscess  is  not 
pointing  toward  the  pleura  or  has  not  ruptured  into  it,  the  liver  is  reached  by 
preference  through  the  peritoneal  cavity  by  making  an  incision  high  up  through  the 
right  rectus  abdominis  muscle.  The  abdominal  cavity  is  carefully  walled  off  by 
gauze  pads.  If  the  abscess  is  not  readily  discovered,  the  liver  may  be  explored  by 
means  of  an  aspirating  needle.  The  abscess  is  then  incised  freely  and  the  cavity 
packed  with  iodoform  gauze.  Other  pieces  of  iodoform  gauze  are  so  arranged  as 
to  protect  the  general  peritoneal  cavity  and  are  brought  out  through  the  inci- 
sion. 

In  cases  in  which  the  abscess  is  evident  on  exposure  of  the  liver  the  operation 
may  be  done  in  two  stages.  The  surface  of  the  liver  at  the  point  of  suppuration  is 
exposed,  and  the  wound  is  packed  with  iodoform  gauze  and  left  three  or  four  days 
until  adhesions  have  formed,  when  the  operation  is  completed. 

In  passing  through  the  pleura  it  is  necessary  to  resect  one  or  more  ribs.  When 
the  parietal  pleura  is  incised,  its  edges  are  caught  by  hemostatic  forceps.  The 
diaphragmatic  pleura  is  now  incised  and  its  margin  sewed  to  that  of  the  parietal 
pleura  so  as  to  close  the  pleural  cavity.  The  operation  is  completed  by  incising 
through  the  diaphragm  and  draining  the  abscess  freely. 

In  cases  in  which  there  is  redness  and  edema  of  the  skin,  making  it  evident  that 
adhesions  exist,  the  abscess  may  be  incised  directly. 

Johnston^  says:  "Treatment  should  be  prompt,  bold,  and  radical.  No  measure 
will  succeed  which  does  not  completely  evacuate  the  abscess  cavity  and  allow  free 
drainage.  This  can  be  done  with  precision  and  safety  only  by  incision.  Aspira- 
tion, puncture  with  trocar,  direct  puncture  with  scalpel,  opening  by  caustics  or  the 
thermocautery  are  uncertain,  insufficient,  dangerous,  and  unsurgical,  and  are  men- 
tioned only  to  be  condemned."  He  reports  eighteen  cases  of  abscess  of  the  liver. 
The  first  eleven  were  treated  by  aspiration :  ten  died,  one  recovered.     In  the  second 

^  Loc.  cit. 


HYDATIDS    OF   THE    LIVER.  311 

group  of  seven  cases,  two  refused  operation;  both  died.     Five  were  treated  by  inci- 
sion and  drainage,  four  recovered  and  one  died. 

O'Conor^  reports  six  cases  of  abscess  of  the  hver,  all  treated  by  incision  and  drain- 
age.    Five  recovered,  one  died. 


HYDATIDS  OF  THE  LIVER. 

This  disease  is  caused  by  a  parasite  known  as  the  tcBnia  echinococcvs,  whose 
normal  habitat  is  the  intestinal  canal  of  dogs,  jackals,  and  wolves.  The  disease 
is  most  prevalent  in  Australia  and  in  Iceland,  where  the  natives  are  not  cleanly  and 
live  in  close  association  with  these  animals. 

The  taeniae  are  taken  into  the  alimentary  canal  with  the  food,  or  more  commonly 
with  drinking-water.  According  to  Fowler,^  their  albuminous  envelop  is  partly 
digested  in  the  stomach,  and,  thus  set  free,  they  burrow  into  the  tissues  and  most 
frequently  enter  a  radicle  of  the  portal  vein  and  are  thus  carried  to  the  liver. 

There  is  seme  question  as  to  what  becomes  of  the  liver  tissue  when  these  large 
cysts  develop  in  the  organ.  Some  authors  believe  that  an  atrophy  takes  place, 
while  others  think  that  a  hypertrophy  occurs.  Frank^  believes  that  the  liver 
tissue  is  never  destroyed  to  any  physiologic  extent,  but  that  by  the  slow  growth  of 
the  cyst  within  the  liver  the  organ  gradually  becomes  compressed,  as  a  lung  would 
be  by  a  pleural  effusion. 

When  the  cyst  is  fully  developed  there  is  a  sac  filled  with  fluid  in  which  float 
smaller  cysts  known  as  daughter  cysts,  and  sometimes  there  are  tertiary  cysts  inside 
of  these. 

The  booklets  of  the  parasite  are  usually  found  in  the  cyst  wall. 

The  cysts  may  exist  for  many  years  and  only  be  discovered  at  autopsy.  The 
great  danger  is  that  they  may  rupture ;  however,  this  is  not  necessarily  fatal,  as  they 
may  rupture  externally  or  into  the  intestinal  canal.  A  cure  may  result  in  this  man- 
ner. If  the  rupture  occurs  into  the  pleural  cavity,  gall-bladder,  or  peritoneal  cavity, 
it  is  almost  invariably  fatal.  If  infection  occurs,  the  disease  may  resemble  a  liver 
abscess. 

Symptoms. — The  symptoms  vary  according  to  the  size  and  the  location  of  the 
cyst.  When  large  and  near  the  surface,  it  may  be  felt  as  a  globular  tumor,  rather 
elastic  and  sometimes  fluctuating.  If  the  tumor  is  behind  the  liver,  there  may  be  no 
symptoms  at  all.  Most  patients  complain  of  a  sense  of  distress  and  weight  in  the 
hepatic  region.  As  the  tumor  grows  there  may  be  pressure  symptoms,  as  dyspnea 
and  cough,  from  extension  upward  to  the  diaphragm.  Pressure  on  the  portal  vein 
may  result  in  ascites,  jaundice,  or  hemorrhoids.  The  hydatid  fremitus  or  San- 
torini's  booming  sound  is  seldom  present.  It  is  present  only  when  the  daughter 
cysts  swim  in  the  fluid. 

'  O'Conor,  John:  "Clinical  Contribution  to  the  Surgery  of  the  Liver,"  Ann.  Surgery,  1897, 
XXV,  547. 

^  Fowler,  Russell  S.:   "Tumors  of  the  Liver,"  Brooklyn  Med.  Jour..  1900,  xiv,  943. 

^  Frank,  Jacob:  "Hydatids  of  the  Liver,"  Amer.  Jour.  Med.  Sci.,  1896,  cxii,  437. 


312  OPERATIONS    UPON   THE    GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

Diagnosis. — The  diagnosis  is  often  difficult,  as  many  of  these  patients  may 
remain  in  good  health  for  years.  It  may  be  differentiated  from  cancer  and  abscess 
by  the  long  history,  slow  growth,  the  absence  of  loss  of  weight,  and  the  lack  of  the 
pronounced  constitutional  symptoms  present  in  abscess.  Its  shape  and  absence 
of  biliary  symptoms  rule  out  gall-bladder  disease.  The  fact  that  the  colon  does 
not  overlie  the  tumor  rules  out  cystic  or  sarcomatous  kidney. 

Treatment. — The  treatment  consists  of  evacuation  of  the  cyst  contents  and 
removal  of  the  lining  of  the  cyst  cavity  and  drainage  of  its  cavity,  or,  in  a  few  selected 
cases  in  which  the  cyst  is  pediculated,  excision  of  the  entire  cyst. 

The  operation  of  drainage  of  the  cyst  may  be  done  in  two  stages  after  the  method 
of  Volkmann,  which  consists  of  opening  the  peritoneal  cavity  and  placing  sterile 
gauze  pads  between  the  cyst  wall  and  the  peritoneum  to  cause  adhesions  to  form 
between  the  hver  and  the  peritoneum,  or  suturing  the  cyst  wall  to  the  peritoneum, 
and  three  or  four  days  later  opening  and  draining  the  cyst. 

O'Conor^  has  found  that  the  cyst  wall  is  usually  so  thin  that  it  is  impossible  to 
suture  it  to  the  peritoneum  without  leakage  of  fluid  around  the  stitches. 

The  operation  commonly  done  consists  of  making  an  incision  over  the  most  promi- 
nent part  of  the  swelling,  then,  after  carefully  packing  away  the  stomach  and  the 
intestines  with  sterile  gauze  pads,  a  trocar  is  inserted  into  the  cyst  and  as  much  fluid 
as  possible  is  withdrawn.  The  cyst  is  then  incised  and  the  remainder  of  its  contents 
sponged  out.  The  lining  of  the  cyst,  which  is  known  as  the  parasite  endocyst,  is 
removed.  The  edges  of  the  cyst  are  sutured  to  the  peritoneum  and  the  cyst  cavity 
is  packed  with  gauze.  The  after-treatment  consists  in  gradually  diminishing  the 
amount  of  packing  at  each  dressing  until  the  cyst  cavity  is  obliterated. 


INJURIES  OF  THE  LIVER. 

The  liver  is  apt  to  be  injured  by  crushing  accidents,  as  when  a  heavy  wagon- 
wheel  passes  over  the  body;  also  by  blows  or  falls  breaking  one  or  more  ribs, 
which  puncture  the  liver,  or  from  penetrating  wounds. 

The  symptoms  of  rupture  of  the  liver  are  those  of  internal  hemorrhage  and  severe 
shock,  such  as  extreme  pallor  and  cold  skin,  feeble  and  rapid  pulse,  and  sighing  res- 
piration ;  the  abdomen  becomes  swollen  and  tympanitic  and  sometimes  there  is  dull- 
ness on  percussion  from  the  collection  of  blood.  Often  there  are  vomiting,  thirst, 
and  syncope. 

Treatment. — The  treatment  should  be  directed  toward  the  control  of  hemor- 
rhage as  soon  as  possible  and  to  prevent  the  retention  of  bile  in  the  peritoneal  cavity 
on  account  of  its  liability  to  cause  cholemia. 

If  from  the  parts  involved  it  is  thought  that  an  injury  to  the  liver  is  in  the  left 
lobe,  or  if  it  is  undetermined,  a  median  incision  is  indicated. 

In  wounds  of  the  right  lobe  a  longitudinal  incision  is  made  through  the  outer  edge 

1  O'Conor,  John:  "Clinical  Contribution  to  the  Surgery  of  the  Liver,"  Ann.  Surgery,  1897, 
XXV,  547. 


INJURIES    OF   THE   LIVER. 


313 


of  the  right  rectus  abdominis  muscle,  and  then,  if  found  necessary,  this  may  be  con- 
verted into  the  "  S  "-shaped  incision,  as  suggested  by  Bevan,  or  into  the  Robson  inci- 
sion. 

Wounds  of  the  hver  may  be  treated  by  suture,  cautery,  gauze  tampon,  or  by 
suturing  a  piece  of  sterile  gauze  down  upon  the  bleeding  surface. 

In  the  majority  of  cases  a  little  pressure  by  means  of  a  gauze  pad  for  a  few  min- 
utes will  control  the  hemorrhage.  In  some  cases  it  may  be  necessary  to  make  con- 
tinuous pressure  over  the  bleeding  surface.     This  may  be  done  by  suturing  a  piece 


Fig.  559. — Shows  Liver  after  Wedge-shaped  Piece  of  Liver  Tissue  has  been  Removed  (after  Jacob  Frank). 


of  iodoform  gauze  over  the  bleeding  surface  by  a  few  catgut  stitches  and  bringing 
one  end  up  through  the  abdominal  wall.  The  gauze  will  make  a  continuous  pres- 
sure and  the  stitches  will  prevent  the  displacement  of  the  gauze  should  the  patient 
cough  or  vomit. 

If  an  injury  is  extensive,  it  is  well  to  pass  the  catgut  sutures  entirely  through 
the  liver  and  through  a  piece  of  iodoform  gauze  on  the  opposite  side  of  this  organ 
in  order  to  prevent  cutting  of  the  sutures.  The  catgut  will  be  absorbed  in  a  few 
days,  so  that  the  gauze  may  then  be  readily  removed. 

In  large  wounds  with  considerable  destruction  of  the  liver  tissue  it  is  better  to  use 


314  OPERATIONS    UPON   THE   GALL-BLADDER,    BILE-DUCTS,    AND    LIVER. 

the  method  of  suture  devised  by  Frank.^  He  excises  a  portion  of  the  liver,  as  shown 
in  Fig.  559,  removing  a  wedge-shaped  piece  of  Kver  tissue,  leaving  the  organ  with 
two  flaps  forming  a  trough.  If  there  is  much  bleeding  from  the  liver  tissue,  it  is 
controlled  by  ligating  the  bleeding  vessel  or  by  passing  a  mattress  catgut  suture 
through  the  entire  thickness  of  the  liver  surrounding  the  vessel. 

For  suturing  the  hver  a  non-cutting  needle  should  be  used.  The  blunt  needle 
devised  by  Kousnietzoff,  shown  in  Fig.  560,  is  very  satisfactory.  The  straight 
needle  should  be  used  in  placing  mattress  sutures  and  the  curved  one  for  ordinary 
suturing.  The  flaps  are  now  coaptated.  With  a  long  non-cutting  needle  threaded 
with  catgut  a  running  stitch  (Fig.  561)  is  commenced  at  one  end  and  continued  as 
foflows:  One  suture  is  carried  through  the  liver  tissue  near  the  bottom  of  the  trough 
and  then  one  superficially,  and  so  on  alternating.  It  requires  but  little  pressure  to 
control  all  the  bleeding. 

Crile  has  shown  that  the  blood-pressure  is  very  low  in  the  liver  and  that  most 


'7- -I — -- -^"1 — r nnniiirr— ^  ~— ^-- — -~— ■»---— -^ :-..^r.-.^.,^.-v.^^,,:-^-^»^-.^..ii-..i..,,..-.-— .iii^«i».Ma.»Bmiw!-T^ 

0 

6 

Fig.   560. — Kousnietzoff's   Blunt   Needles  for   Suturing  the   Liver. 

of  the  bleeding  from  a  cut  surface  is  venous.     The  main  object  is  to  bring  the  two 
flaps  together  in  perfect  coaptation,  obliterating  all  dead  spaces. 

The  continuity  of  the  liver  surface  is  re-established  and  no  raw  area  or 
ragged  edge  is  left. 

SUBPHRENIC  ABSCESS. 

Subphrenic  abscess  is  a  locaHzed  collection  of  pus  between  the  under  surface 
of  the  diaphragm  and  any  of  the  adjacent  abdominal  organs.  It  may  be  intra- 
peritoneal or  extraperitoneal,  and  the  abscess  is  more  frequently  found  upon  the 
right  side. 

The  most  common  source  of  infection  is  from  the  extension  of  a  local  inflamma- 
tory condition.     It  may  also  occur  as  a  localization  in  the  subphrenic  space  of  a 

1  Frank,  Jacob:  "Incising  and  Suturing  the  Liver,"  Jour.  Amer.  Med.  Assoc,  1905,  xlv,  446. 


SUBPHRENIC    ABSCESS. 


315 


general  infection,  the  infectious  material  being  carried  to  the  subphrenic  region  by 
the  blood-current.  Direct  extension  of  an  infection  of  the  appendix  may  be  spread 
upward  by  two  routes,  one  intraperitoneally  along  the  outer  side  of  the  colon  to  the 
liver,  then  between  the  liver  and  the  diaphragm,  or  from  the  loose  cellular  tissue 
behind  the  cecum,  then  upward  behind  the  colon  and  liver  to  the  subphrenic  space. 

Subphrenic  abscess  may  be  secondary  to  disease  of  the  gall-bladder  and  biliary 
passages. 

Abscess  of  the  liver  may,  in  its  late  stage,  extend  beyond  the  liver  to  the  dia- 


FiG.   561. — Shows  Coaptation   of  Liver  Surfaces   (after  Jacob  Frank). 

phragmatic  space.  Occasionally  the  infection  comes  from  a  slow  perforating  ulcer 
of  the  stomach  or  duodenum,  or  from  inflammation  of  the  pancreas,  intestines, 
spleen,  or  from  some  of  the  various  suppurative  processes  of  the  kidneys. 

Subphrenic  abscess  may  follow  an  empyema  of  the  pleural  cavity.  In  seventy- 
three  cases  following  appendicitis  which  Elsberg^  has  collected  "in  the  literature, 
the  abscess  was  extraperitoneal  in  twenty-three  cases,  intraperitoneal  in  thirty-five 
cases,  the  anatomic  location  doubtful  in  eighteen  cases. 

Symptoms  of  subphrenic  abscess  may  come  on  days,  weeks,  or  months  after  an 
appendicitis  or  any  intra-abdominal  disease  which  may  lead  to  it. 

1  Elsberg,  Charles  A.:  "A  Contribution  to  the  Pathology,  Diagnosis,  and  Treatment  of  Sub- 
phrenic Abscesses  after  Appendicitis,"  Ann.  Surgery,  1901,  xxxiv,  729. 


316  OPERATIONS   UPON   THE   GALL-BLADDER,    BILE-DUCTS,   AND    LIVER. 

The  mode  of  onset  differs  greatly.  In  some  the  symptoms  are  not  severe :  the 
patient  begins  to  complain  of  pain  over  the  lower  part  of  the  right  chest,  the  tem- 
perature begins  to  rise,  the  area  of  liver  dullness  is  somewhat  enlarged,  and  there 
are  friction  sounds  over  the  hepatic  region  and  tenderness  over  one  or  more  inter- 
costal spaces.  In  a  few  days  the  pain  becomes  less  and  the  signs  of  fluid  more 
marked. 

In  other  cases  the  patient  looks  very  ill  from  the  beginning;  he  has  a  fever  of  a 
remittent  type,  loses  flesh  and  strength  rapidly,  has  pain  in  the  upper  abdomen, 
usually  on  the  right  side,  loss  of  appetite,  and  complains  of  a  sense  of  pressure  in  the 
epigastrium  and  an  interference  with  respiration.  Later  a  bulging  of  the  abscess 
appears. 

There  is  still  another  class  of  patients,  who,  after  having  recovered  from  an 
attack  of  appendicitis,  do  not  regain  their  former  strength.  Without  any  change 
of  temperature  or  pulse  the  patient  complains  of  a  continual  slight  pain  in  the 
right  chest.  The  pain  may  persist  for  weeks  and  the  patient  may  not  look  ill. 
After  a  time  the  presence  of  fluid  under  the  diaphragm,  and  perhaps  also  in  the 
pleural  cavity,  is  discovered  by  physical  examination  and  the  aspirating  needle. 

Diagnosis. — The  diagnosis  of  subphrenic  abscess  is  often  difficult,  especially 
if  there  is  no  free  gas  in  the  cavity.  If  there  is  a  pleural  effusion  at  the  same  time, 
it  is  still  more  difficult.  On  the  right  side  posteriorly  there  will  be  dullness,  and  if 
there  be  no  gas  present,  the  liver  dullness  will  be  continuous  with  that  produced  by 
the  pus. 

The  upper  edge  of  this  dull  area  will  be  convex.  The  physical  signs  of  such  a 
case  are  almost  the  same  as  those  of  liver  abscess.  If  there  is  gas  present  in  the 
abscess  cavity,  the  signs  are  quite  characteristic.  There  will  be  three  areas  of  differ- 
ent resonance,  one  above  the  other.  Above  we  will  have  the  resonance  of  the  lung, 
below  this  the  tympany  of  the  gas,  and  still  lower  the  dullness  of  the  fluid,  which 
merges  into  the  liver  dullness. 

Abscesses  on  the  left  side  practically  always  contain  gas,  as  they  usually  come 
from  the  stomach  or  duodenum.  An  abscess  on  the  right  side  may  push  the  liver 
downward.     On  both  sides  a  bulging  of  the  chest  or  abdominal  wall  may  be  seen. 

The  diagnosis  in  all  cases  should  be  verified  by  the  aspirating  needle,  inserted 
over  the  most  sensitive  part  of  the  dull  area. 

Prognosis. — Elsberg^  quotes  Maydl  as  reporting  a  mortality  of  35.7  per  cent, 
in  operative  cases  and  a  general  mortality  of  all  cases  as  56  per  cent.  Sonnenberg 
reckons  that  55.5  per  cent,  of  the  unoperated  cases  die  and  42  per  cent,  of  the  oper- 
ated cases. 

Elsberg  collected  seventy-three  cases  as  follows: 

Died  with  operation,  11  cases 15  per  cent. 

Died  without  operation,  18  cases    25 

Total  mortality 40 

Cured  with  operation,  40  cases 55 

Cured  without  operation,  4  cases 5 

Total  cures 60 

^  Loc.  cit. 


SUBPHRENIC   ABSCESS.  317 

Treatment. — The  abscess  may  be  reached  by  incision  through  the  chest  wall 
and  diaphragm  or  by  an  incision  through  the  abdominal  wall. 

The  transpleural  operation  is  most  often  employed.  An  incision  three  to  five 
inches  long  is  made  over  the  ninth  or  tenth  ribs  on  the  right  side  or  the  seventh  or 
eighth  on  the  left  side;  the  middle  of  the  incision  having  been  determined  by  the 
point  from  which  pus  was  withdrawn  by  the  aspirating  needle,  about  three  inches 
of  each  rib  is  resected  and  the  condition  of  the  pleural  cavity  determined. 

If  the  pleural  cavity  is  not  infected,  it  must  be  protected  from  infection,  either 
by  packing  with  gauze  and  waiting  for  the  second  step  of  the  operation  for  twenty- 
four  hours,  or  by  the  introduction  of  stitches  which  include  both  layers  of  the  pleura 
and  the  diaphragm  and  the  chest  wall.  The  margins  of  the  wound  are  further  pro- 
tected with  iodoform  gauze,  and  then  the  diaphragm  is  incised  and  the  abscess  cavity 
thoroughly  drained. 

Incision  through  the  anterior  abdominal  wall  is  suited  to  those  cases  in  which 
there  is  a  large  abscess  bidging  in  the  epigastrium.  An  incision  is  made  high  up 
over  the  bulging  area  which  opens  into  the  abscess.  The  pus  is  evacuated,  and 
these  cavities  are  usually  best  drained  by  placing  a  counter-drain  through  the  loin, 
draining  both  anterior  and  posterior  incisions. 


CHAPTER  XXXIII. 

OPERATIONS  UPON  THE  STOMACH. 

By  B.  G.  a.  Moynihan,  F.  R.  C.  S. 

PREPARATORY  TREATMENT  AND  INVESTIGATION  OF  THE  STOMACH. 

It  is  highly  important  that  the  contents  of  the  stomach  should  be  as  free  from 
germs  as  possible  at  the  time  when  this  portion  of  the  digestive  tract  is  to  be  oper- 
ated upon.  It  is  to  Harvey  Gushing  that  we  are  indebted  for  the  demonstration 
that  such  a  condition  of  asepsis  is  attainable.  His  first  observations  in  this  direc- 
tion were  upon  a  man  who,  as  the  result  of  a  wound,  developed  a  high  jejunal 
fistula.  In  tliis  case  it  was  found  that  there  was  a  marked  diminution  in  the  number 
of  the  organisms  growing  in  cultures  from  the  fistulous  discharge  after  the  patient 
had  been  kept  for  a  day  or  two  on  a  sterile  diet,  special  attention  being  paid  at  the 
same  time  to  the  hygiene  of  the  mouth.^ 

It  has  also  been  shown  that  after  a  period  of  starvation  the  stomach  and  upper 
part  of  the  intestine  are  practically  sterile. 

Although  these  methods  may  be  sufficient  when  dealing  with  the  healthy  indi- 
vidual, there  are  certain  pathologic  changes  in  the  stomach,  particularly  those  calling 
for  surgical  intervention,  where  the  vegetable  flora  persist  even  after  starvation. 
This  is  especially  well  seen  when  the  outlet  of  the  stomach  is  blocked  by  an  ulcerat- 
ing growth;  the  organ  is  unable  to  empty  itself,  the  secretion  of  hydrochloric  acid 
is  in  abeyance,  or,  if  present,  in  so  small  a  quantity  that  it  is  probably  neutralized 
by  the  albuminous  discharges  from  the  surface  of  the  growth.  The  stagnant  con- 
tents of  such  a  stomach  form  a  favorable  medium  in  which  many  species  of  micro- 
organisms flourish;  and  though  many  of  these  forms  are  probably  non-parasitic, 
yet  even  saprophytes  are  undesirable  as  possible  invaders  of  the  peritoneum. 

Again,  the  contents  of  a  dilated  stomach  secondary  to  a  fibrous  stricture  beyond 
the  pylorus,  or  to  active  ulceration  in  this  region  associated  with  an  increased  acidity 
of  the  gastric  juice,  will  be  found  to  contain,  even  after  a  period  of  fasting,  other 
forms  of  vegetable  life,  as  saccharomyces  and  sarcinse. 

Since  it  is  clear  that  mere  abstinence  from  food,  or  the  administration  of  only 
sterile  fluid  foods,  is  not  always  enough  to  rid  the  stomach  of  bacteria,  it  is  necessary 
to  make  use  of  the  stomach-tube  for  the  purpose  of  mechanically  washing  the  stom- 
ach. 

With  a  few  exceptions,  such  as  cases  of  cancer  of  the  esophagus  or  cardiac  orifice, 
perforated  ulcer,  or  one  which  has  recenUy  bled,  gastric  lavage  should  be  regarded 

1  Gushing,  Harvey:  "Remarks  upon  a  Case  of  Jejunal  Fistula,"  Johns  Hopkins  Hosp.  Bull., 
July,  1899,  X,  136. 

318 


PREPARATORY    TREATMENT   AND    INVESTIGATION    OF   STOMACH.  319 

as  the  routine  preliminary  to  operative  treatment;  the  advantages  He  not  onlv  in  the 
direction  of  antisepsis,  but  may,  from  the  diagnostic  point  of  view,  prove  of  the 
utmost  value.  If  the  importance  of  the  procedure  be  clearly  explained  beforehand, 
there  will  be  found  very  few  patients  who  refuse  to  submit  to  it ;  and  if  the  passage 
of  the  tube  be  performed  with  care  and  gentleness  it  is  safe  to  assure  the  patient 
that  repetition  will  be  less  unpleasant  than  the  first  procedure.  The  cases  suffering 
most  from  gastric  lavage  are  those  in  which  there  are  adhesions  to  the  under  surface 
of  the  liver  or  diaphragm;  in  these  cases  there  is  not  likely  to  be  much  dilatation 
or  need  for  washing  the  stomach. 

As  of  almost  equal  importance  to  the  washing  are  to  be  reckoned  the  care  of  the 
mouth  and  teeth  and  the  sterilization  of  the  food.  A  rational  combination  of  these 
precautions  is  an  essential  preliminary  to  all  operations  upon  the  stomach. 

The  preparatory  treatment  should  begin  not  less  than  two  days  before  the  opera- 
tion, while,  if  the  diagnosis  needs  to  be  decided  by  laboratory  methods,  a  longer 
time  may  be  desirable.  The  routine  treatment  is  then  carried  out  as  follows:  As 
soon  as  the  patient  is  admitted  the  stomach-tube  is  passed  and  any  material  in  the 
stomach  withdrawn,  and  labeled  "A"  and  kept  for  examination,  the  time  and 
character  of  the  last  meal  being  also  noted.  The  stomach  is  washed  out  until  the 
returning  fluid  is  clear,  the  stomach  is  finally  emptied  and  then  distended  with  air 
by  means  of  a  rubber  syringe;  meanwhile  the  patient  is  made  to  lie  down  with  the 
abdomen  uncovered  and  the  shape  and  size  of  the  stomach  carefully  observed. 
An  aperient  is  then  given  and,  the  last  thing  at  night,  the  patient  is  required  to  eat 
a  fairly  heavy  meal  consisting  of  meat,  vegetables,  etc. ;  nothing  is  then  taken  for 
about  eight  to  ten  hours,  when  the  stomach-tube  is  again  passed,  any  contents  re- 
moved and  labeled  "B,"  and  the  stomach  again  washed  clear.  At  the  end  of  this 
washing,  before  the  tube  is  withdrawn,  the  stomach  is  filled  with  water,  a  saline 
aperient  is  administered,  and  thereafter  the  patient  is  allowed  nothing  but  sterilized 
liquids.  On  the  evening  before  operation  the  stomach  is  again  washed  out,  and 
the  patient  then  allowed  nothing  but  sterilized  water,  of  which,  however,  he  is 
encouraged  to  drink  freely.  If  it  is  necessary  to  give  the  patient  a  test  meal  of  dry 
toast  and  tea,  this  may  be  done  before  the  third  washing,  on  the  eve  of  the  operation 
if  time  presses,  but  where  possible  time  should  be  allowed  for  this  not  less  than 
twenty-four  hours  before  operation  and  labeled  "C."  During  this  period  of 
preparation  the  patient  must  brush  his  teeth  and  rinse  his  mouth  with  a  mildly 
antiseptic  lotion  frequently  and  thoroughly.  A  few  cubic  centimeters  of  the  feces 
should  be  reserved  for  examination,  and  if  there  is  any  uncertainty  as  to  the 
diagnosis,  an  examination  of  the  blood  should  be  made  between  one  and  two 
hours  after  the  full  meal,  and  again  at  the  end  of  the  eight  hours'  fast. 

It  will  be  seen  that  while  the  tube  is  passed  primarily  for  cleansing  purposes, 
the  opportunity  it  affords  for  obtaining  material  to  aid  or  confirm  the  diagnosis  is 
not  neglected.  As  to  the  manner  in  which  this  material  may  be  utilized:  among 
the  many  laboratory  tests  which  have  been  devised  for  the  purpose  of  differentiating 
pathologic  conditions  of  the  stomach  there  are  a  few  which  may  be  simply  carried 


320  OPERATIONS  UPON  THE  STOMACH. 

out  and  from  which  in  their  relation  with  one  another  certain  inferences  may  be 
deducted.  These  investigations  are  concerned  with  the  presence  or  absence  of 
food  residue,  blood,  free  HCl,  lactic  acid,  yeast,  sarcinse,  other  micro-organisms, 
pus,  and  other  cellular  elements  in  the  specimens  of  stomach  contents  (A.  B.  C), 
the  presence  or  absence  of  blood  in  the  feces,  and  the  presence  or  absence  of  a  di- 
gestion leukocytosis. 

For  the  proper  interpretation  of  the  results  of  tests  of  the  stomach  contents, 
blood,  and  feces,  it  is  essential  that  these  results  should  be  viewed  in  their  relation 
one  with  another.  Few  of  the  tests  can  stand  alone  with  any  diagnostic  weight,  and 
then  only  when  the  results  obtained  under  different  conditions  conform  to  certain 
rules. 

Before  considering  the  deductions  which  may  be  drawn  from  the  whole  series 
of  different  tests  upon  a  given  case,  it  will  be  advisable,  in  order  to  obtain  a  just 
estimate  of  their  individual  value,  to  review  each  test  separately. 

1.  The  Amount  of  Residue  Visible  to  the  Naked  Eye  in  the  Stomach  Contents. — If 
there  remains  any  food  in  the  stomach  after  a  fast  of  eight  hours  it  may  be  assumed 
that  there  is  some  impediment  to  the  onward  passage  of  food.  If  the  stomach 
contains  food  debris  after  this  lapse  of  time,  and  is  colored  with  blood,  it  is  obvious 
that  the  bleeding  is  on  the  proximal  side  of  the  obstruction;  but  if  the  stomach  con- 
tains blood  unmixed  with  the  remains  of  food,  there  may  yet  be  a  perfectly  free  outlet 
to  the  stomach,  and  the  blood  may  be  of  gastric  or  duodenal  origin. 

2.  The  Chemical  Test  for  Blood. — This,  if  positive,  is  of  little  value  alone;  traces 
of  blood  may  be  derived  from  the  pharynx,  esophagus,  stomach,  or  duodenum. 
This  test  is  so  delicate  that  traces  of  blood  due  to  some  slight  injury  in  passing  the 
stomach-tube  may  give  rise  to  error  unless  a  pre\-ious  specimen  of  the  stools  be 
examined  at  the  same  time.  The  constant  recognition  of  traces  of  blood  in  the 
gastric  contents  and  in  the  stools  is  suggestive  of  either  malignant  growth  in  the 
stomach,  or  active  ulceration  in  the  stomach  alone,  or  in  the  stomach  and  duodenum; 
but  it  cannot  be  taken  as  negativing  the  existence  of  a  duodenal  ulcer  only. 

3.  Lactic  Acid. — The  presence  or  absence  of  this  has  very  little  value  in  itself. 
Even  when  taken  in  conjunction  with  other  tests  it  can  only  be  considered  of  con- 
firmatory importance.  In  the  presence  of  free  HCl  it  is  scarcely  necessary  to  test 
for  it,  while  it  is  frequently  present  in  cases  of  carcinoma  if  HCl  is  absent. 

4.  Free  HCl. — Of  all  the  tests  regarded  singly,  that  for  the  detection  of  HCl  is 
perhaps  the  most  valuable.  To  be  reliable,  however,  it  needs  to  be  demonstrated 
under  different  conditions.  If  absent  after  a  fast  of  eight  hours  and  present  one 
hour  after  a  test  meal  the  stomach  may  be  normal,  there  may  be  obstruction  in  the 
neighborhood  of  the  pylorus  or  duodenum  due  to  causes  not  arising  therein,  there 
may  be  only  gastroptosis,  or  there  may  be  a  duodenal  ulcer  without  constriction, 
or  occasionally  a  gastric  ulcer  away  from  the  pylorus.  If  HCl  is  present  in  any 
quantity  both  after  the  test  meal  and  after  a  prolonged  abstinence  from  food,  it  is 
probable  that  there  is  a  pyloric  ulcer  or  a  duodenal  ulcer  with  gastrectasis.  If  HCl 
is  absent  on  both  occasions,  or  only  faintly  present  after  a  test  meal,  it  is  extremely 
probable  that  the  patient  is  suffering  from  a  cancerous  growth. 


PREPARATORY   TREATMENT   AND    INVESTIGATION   OF   STOMACH.  321 

5.  Yeast  and  sarcinse  are  found  in  the  stomach  after  fasting  only  when  there  is 
stasis  of  food.  The  presence  of  a  gastric  secretion  containing  HCl  appears  to  be 
necessary  for  their  occurrence;  though  this  may  not  be  recognized  in  the  contents 
after  an  eight  hours'  fast,  yet  its  presence  is  to  be  expected  during  digestion.  Sac- 
charomyces  and  sarcinse  may  occur  together,  or  one  or  the  other  may  predominate. 
They  will  usually  be  found  unaccompanied  by  any  number  of  other  organisms; 
and  if  there  is  stasis  in  association  with  achlorhydria,  they  are  rarely  met  with. 
Their  significance  lies  in  the  fact  that  they  develop  in  the  stomach  in  the  presence 
of  free  hydrochloric  acid  when  the  onward  passage  of  the  gastric  contents  is  delayed 
from  any  cause. 

6.  Bacteria  are  not  found  in  any  quantity  in  the  fasting  stomach  unless  the  pro- 
cess of  digestion  is  imperfect  by  reason  of  a  deficiency  in  the  secretion  of  hydro- 
chloric acid.  Short  bacilli  with  rounded  ends,  diplococci,  staphylococci,  and  strep- 
tococci are  the  most  usual  forms,  but  a  long  slender  bacillus  may  be  found  with 
squarely  cut  ends,  often  slightly  curved,  which  retains  the  stain  in  Gram's  method — 
the  B.  geniculatus  or  Oppler-Boas  bacillus — to  which  a  special  interest  attaches. 
The  organism  has  been  given  pathognomonic  value  in  the  diagnosis  of  cancer  of 
the  stomach.  Though  it  is  certainly  often  met  with  in  cases  of  this  disease,  yet, 
in  the  stomach  contents,  it  is  always  associated  with  other  forms  of  bacteria  whose 
presence  testifies  to  the  absence  or  diminution  in  the  secretion  of  HCl,  and,  when 
occurring  in  any  number  after  an  eight  hours'  fast,  suggests  pyloric  obstruction. 
It  is  to  be  noted  that  the  presence  of  bacilli,  cocci,  etc.,  in  the  fasting  stomach  has 
not  the  same  significance,  as  regards  stasis,  as  is  possessed  by  the  presence  of  yeast 
cells  and  sarcinse  under  the  same  conditions;  the  irregular  surface  of  a  malignant 
growth  may  harbor  enormous  numbers  of  organisms  in  its  interstices  without  en- 
croaching upon  the  outlet  of  the  stomach. 

7.  Pus  cells  are  not  often  found  in  any  numbers;   they  are  not  often  to  be  recog- 
nized in  cases  of  simple  ulcer,  but  may  be  seen  where  there  in  an  extensive  ulcerating . 
growth  in  the  stomach.     Large  quantities  of  pus  would  indicate  the  evacuation  of 
a  perigastric  abscess  into  the  stomach. 

8.  Epithelial  Cells,  Fragments  of  Tissue,  etc. — It  is  not  often  that  fragments  of 
growth  of  sufficient  size  are  removed  by  the  stomach-tube  to  throw  any  certain  light 
on  the  diagnosis.  Squamous  epithelial  cells  may  often  be  found  under  the  micro- 
scope; these  have  been  scraped  from  the  wall  of  the  pharynx  or  esophagus.  It  is 
unusual  to  meet  with  red  blood-cells  unless  there  has  been  an  evident  hemorrhage. 

9.  Examinations  of  the  blood  taken  before  and  after  a  meal  in  order  to  determine 
the  existence  of  a  digestion  leukocvtosis  mav  be  of  use  in  deciding  the  diamosis  when 
the  question  of  carcinoma  has  to  be  considered.  Apart  from  this,  the  hemoglobin 
percentage  may  be  of  prognostic  importance  when  considering  the  propriety  of 
operative  interference  after  severe  or  repeated  hemorrhages,  though  the  safe  limit 
will  be  fixed  in  such  cases  by  the  individual  surgeon's  experience.  Occasional!}' 
the  blood  examination  will  be  required  to  decide  between  a  primary  anemia  and 
one  secondary  to  continued  latent  hemorrhages. 

VOL.  II — 21 


322 


OPERATIONS   UPON   THE   STOMACH. 


Fig.  562. — Isoperistaltic  Anastomosis. 


10.  The  chemical  test  for  blood  applied  to  the  feces  will  frequently  give  a  positive 
result  both  in  cases  of  ulcer  and  cancer,  provided  that,  in  the  latter  case,  the  growth 
has  an  ulcerated  surface.  As  already  stated,  the  presence  of  blood  in  the  feces  and 
in  the  stomach  contents  points  to  the  existence  of  an  ulcer  either  in  the  stomach 

alone,  or  in  the  stomach  and  duode- 
num, or  to  carcinoma  of  the  stomach, 
but  cannot  with  certainty  rule  out 
duodenal  ulcer  alone. 


GASTRO-ENTEROSTOMY. 

Definition.  —  Gastro  -  enterostomy 
is  the  name  given  to  the  operation  in 
which  the  stomach  is  anastomosed 
with  the  small  intestine.  Inasmuch 
as  the  part  of  the  intestine  now  always 
selected  for  the  operation  is  the  jeju- 
num, the  term  "gastro-jejunostomy" 
is  frequently  used.  The  jejunum  may 
be  united  to  the  anterior  or  posterior 
surfaces  of  the  stomach,  or  along  its 
inferior  border;    we   speak,   therefore, 

of  "anterior  gastro-enterostomy, "    "posterior  gastro-enterostomy,"   or   "inferior 

gastro-enterostomy. "      The  jejunum  may  be  united  to  the  stomach  so  that  its 

proximal  end  is  to  the  left,  the  peristaltic  wave  in  both  stornach  and  intestine  at 

the    anastomosis    being    from    left    to 

right;    the  anastomosis  is  then  said  to 

be  "isoperistaltic"  (Fig.  562).     If  the 

jejunum  is  applied  to  the  stomach  in 

the  opposite  direction,  the  anastomosis 

is  "antiperistaltic"  (Fig.  563). 

History.— On  September  27,  1881, 

Wolfler,  then  assistant  to   Billroth  at 

Vienna,  was   operating   on   a  case  of 

carcinoma  of   the  stomach,  with   the 

object  of  resecting  the  growth.     This 

was  found  to  be  impossible,  and  the 

abdomen  was  about  to  be  closed,  when 

Nicoladoni,  who  assisted  Wolfler,  sug- 
gested that  a  new  opening  might  be 

made  between   the   stomach   and  the  small  intestine  to  replace  that  which  was 

obstructed  by  the  growth.     This  was  done;   and  in  this  manner  was  introduced 

into  surgical  procedures  an  operation  which  has   had   perhaps   no   rival   in    the 


Fig.  563. — Antiperistaltic  Anastomosis. 


GASTRO-ENTEROSTOMY.  323 

excellence  of  its  results,  and  in  the  immensity  of  the  relief  it  has  afforded  to  those 
doomed  to  constant  suffering  or  to  death. 

Wolfler  united  the  jejunum  to  the  anterior  surface  of  the  stomach  in  an  anti- 
peristaltic direction.  Von  Hacker  was  the  first  to  perform  the  operation  by  the 
posterior  method. 

Conditions  for  Which  the  Operation  is  Performed. — In  cases  of  ulceration 
of  the  stomach : 

Gastric  Ulcer. — Ulceration  of  the  stomach  may  be  acute  or  chronic;  of  the  two 
forms  the  surgical  interest  of  the  latter  is  by  far  the  greater. 

Acute  ulcer  of  the  stomach  may  be  found  at  any  part  of  the  stomach,  and  occurs 
with  great  rarity  in  men.  The  ulcer  is  small,  round  or  oval,  as  though  it  had  been 
"punched  out"  from  the  inner  walls  of  the  stomach,  and  it  is  often  funnel-shaped, 
being  widest  at  the  mucosal  surface,  narrowing  gradually  as  it  penetrates  the  coats 
of  the  stomach. 

Chronic  ulcer  of  the  stomach  is  much  larger,  and  occurs  more  frequently  in 
males.  It  may  be  found  at  any  part  of  the  stomach,  but  in  the  cases  wdiich  come  to 
the  surgeon  it  is  found  more  frequently  at  the  pylorus,  or  on  the  upper  border  of  the 
stomach  a  little  away  from  the  pylorus  ("prepyloric"),  than  at  other  parts. 

Fenwick^  has  collected  1015  cases  of  ulcer  of  the  stomach  and  gives  the  foUow^ing 
table  to  show  the  positions  occupied : 

Cases.  Peecentage. 

Pylorus      158  15.6 

Lesser  curvature 366  36.0 

Posterior  surface 254  25.0 

Cardia 80  7.9 

Greater  curvature 42  4.14 

Anterior  surface 82  8.0 

Fundus 33  3.3 

In  this  table  no  distinction  is  made  between  acute  and  chronic  ulcers.  But  in  his. 
own  series  of  cases  a  distinction  between  the  two  forms  is  made  and  a  marked  differ- 
ence in  their  distribution  is  clearly  seen.  In  109  cases  there  were  70  in  which  a 
chronic  ulcer  was  found:  Of  these,  53  were  found  in  the  pyloric  region,  7  were 
found  in  the  middle  zone,  10  were  found  in  the  cardiac  zone.  Of  the  39  acute 
ulcers,  13  were  found  in  the  pyloric  region,  14  were  found  in  the  middle  zone,  12 
were  found  in  the  cardiac  zone.  Acute  ulceration  therefore  shows  no  special  inci- 
dence in  any  part  of  the  stomach,  while  in  chronic  ulcer  there  is  a  pronounced 
partiality  for  the  pyloric  region. 

So  far  as  sex  incidence  is  concerned  there  can  be  no  question  that  acute  ulcera- 
tion is  more  common  in  women,  especially  young  women,  and  that  chronic  ulcera- 
tion is  more  prevalent  in  men.  The  following  table,  showing  age  and  sex  incidence 
in  89  cases  observed  by  Fen  wick,  is  given  in  his  book: 

'  Fenwick,  Samuel,  and  W.  Soltau  Fenwick:  "Ulcer  of  the  Stomach  and  Duodenum  and  its 
Consequences,"  1900,  pp.  7,  8. 


324 


OPERATIONS    UPON   THE    STOMACH. 


EIGHTY-NINE  CASES  OF  OPEN  ULCER,  ARRANGED  ACCORDING  TO  THE  CHARACTER 
OF  THE  DISEASE  AND  AGE  OF  THE  PATIENT  AT  THE  TIME  OF  DEATH. 


Age. 


10-20 
20-30 
30-40 
40-50 
50-60 
60-70 
70-80 

Total. 


Acute  Ulcers. 


Males.  Females. 


7 
13 

7 


27 


Chronic  Ulcers. 


Males. 


1 

5 
22 
8 
6 
1 

43 


Females. 


16 


No  age  is  exempt  from  this  affection.  Children  may  be  born  with  ulceration  of  the 
stomach  or  duodenum,  and  death  from  perforation  has  been  recorded  by  Porter 
Parkinson  in  a  child  of  two.  I  have  myself  seen  duodenal  ulcer  attended  by  very 
serious  hemorrhage  in  an  infant.  The  statistics  of  Fenwick,  to  which  frequent 
reference  has  been  made,  show  that  while  75  per  cent,  of  cases  of  gastric  ulcer  in 
women  are  found  before  the  age  of  thirty,  only  25  per  cent,  are  found  before  that 
age  in  men.  It  is  shown,  moreover,  that  of  acute  ulcers  over  70  per  cent,  occur 
within  the  first  three  decades  of  life,  while  of  chronic  ulcer  less  than  7  per  cent, 
occur  within  that  period. 

Symptoms.— The  symptoms  and  signs  of  gastric  ulceration  are  of  such  a  kind 
that  in  the  majority  of  cases  a  clear  unhesitating  diagnosis  can  be  given.  But  there 
are  cases  in  which  diseases  in  other  parts,  the  duodenum,  the  gall-bladder,  or  the 
appendix,  may  cause  an  exact  mimicry  of  the  clinical  appearances  of  gastric  ulcer, 
and  there  are  cases  of  the  so-called  "functional"  diseases  of  the  stomach  that  are 
with  difficulty  distinguished  from  those  in  which  organic  disease  is  present.  But 
the  more  exact  the  anamnesis  and  the  more  thorough  the  investigation,  upon  the 
lines  already  laid  down  in  the  opening  chapter,  the  less  frequently  will  these  diffi- 
culties be  encountered.  The  chief  of  the  symptoms  and  signs  of  chronic  gastric 
ulcer  are : 

Pain. — Pain  after  food  is  the  most  constant  and  the  most  reliable  of  all  the  symp- 
toms. In  my  own  experience  where  exact  observations  have  been  made  there  is  a 
definite  relationship  between  the  time  of  the  onset  of  pain  after  a  meal  and  the  posi- 
tion of  an  ulcer  in  the  stomach.  From  two  patients  I  heard  a  complaint  that  pain 
came  almost  the  moment  food  had  reached  the  stomach;  in  both  the  ulcer  was  al- 
most at  the  cardiac  orifice.  If  pain  comes  one  and  one-half  hours  after  food,  the 
ulcer  is  prepyloric  or  pyloric.  The  researches  of  Birmingham  into  the  anatomy  of 
the  stomach  explain  why  it  is  that  there  should  be  this  relationship  between  the 
taking  of  food  and  the  onset  of  pain.     He  has  shown^  that  the  stomach  is  not  an 


^Birmingham,  A.:     "The  Topographical  Anatomy  of  the  Spleen,  Pancreas,  Duodenum, 
Eddneys,  etc.,"  Jour.  Anat.  and  Phys.,  1896,  xxvi,  new  series  vi,  p.  95. 


GASTRO-ENTEROSTOMY.  325 

empty  sac,  to  the  bottom  of  which  fluid  falls,  but  a  contractile  muscular  organ  that 
fills  at  the  cardiac  end  first,  and  little  by  little  passes  the  food  onward  through  the 
pyloric  antrum  and  pylorus  into  the  duodenum.  Food  does  not  come  in  contact 
with  an  ulcer  a  little  distant  from  the  pylorus  until  it  has  lain  in  the  stomach  for  a 
certain  time.  Pain  is  often  acute,  radiating  to  one  or  other  side,  or  penetrating  to 
the  back.  When  the  pain  radiates  upward  to  the  left  or  right  breast  it  indicates 
the  existence  of  adhesions  to  the  diaphragm  or  the  under  surface  of  the  liver.  In 
pyloric  or  duodenal  ulcer  the  pain  is  relieved  by  the  food  for  a  time ;  for  after  inges- 
tion of  food  the  pyloric  antrum  and  pylorus  are  closed,  and  an  ulcer  therein  is  free 
from  the  irritating  contact  with  passing  food. 

Teriderness  is  generally  present  in  cases  where  there  is  any  acute  exacerbation  of 
a  chronic  process.  Mackenzie,  of  Burnley,  has  endeavored  to  show  that  there  is  a 
relationship  between  the  local  tenderness  and  the  position  of  an  ulcer.  If  the 
tenderness  is  high  up  near  the  ensiform  cartilage  and  a  little  to  the  left  of  the  middle 
line,  a  cardiac  ulcer  may  be  suspected;  if  there  is  tenderness  low  down  near  the 
umbilicus,  the  pyloric  region  is  likely  to  be  involved. 

Vomiting  is  not  a  frequent  and  rarely  a  conspicuous  sign  of  gastric  ulcer.  This 
statement,  which  is  contrary  to  that  generally  given,  is  hardly  open  to  question, 
so  far  as  my  own  experience  goes.  The  reason  is  that  patients  by  degrees  come  to 
recognize  what  will  and  what  will  not  cause  pain  or  a  feeling  of  sickness,  and  they 
avoid  that  quantity  or  that  quality  of  food.  It  may  be  said  that  they  take  the  meas- 
ure of  their  stomachs'  capacity,  and  they  keep  within  the  limit  of  its  powers.  Even 
in  cases  where  an  extreme  degree  of  stenosis  has  been  disclosed  at  the  operation  the 
patient  will  say  that  he  has  "never  vomited."  But  if  such  a  patient  be  made  to 
transgress  his  own  limitations,  sickness  and  vomiting  may  be  provoked  at  once. 
In  the  earlier  stages  of  the  disease  vomiting  may  occur,  perhaps  frequently,  and 
blood  may  be  mixed  with  the  ejected  material,  or  blood  may  be  vomited  alone,  .in 
small  or  in  very  large  quantities.  Blood  may  be  found  in  the  stools  even  when 
there  has  been  no  vomiting  at  all;  this  I  have  more  than  once  observed.  ]\Ielena 
is  a  sign  doubtless  often  overlooked. 

Dilatation  of  the  Stomach. — This  term,  which  is  so  widely  used  and  accepted,  is 
unfortunate,  for  mere  bigness  of  the  stomach  means  nothing.  There  is  as  much 
(nay,  far  more)  variation  in  the  size  of  stomachs  as  in  the  size  of  noses.  It  is  not 
size,  but  capacity  for  emptying  itself,  which  is  the  important  point.  A  stomach  may 
be  of  any  size,  within  reasonable  limits,  so  that  every  one  would  acknowledge  it 
to  be  a  "dilated  stomach";  but  if  it  empties  itself  of  food  within  six  or  eight  hours, 
it  is  performing  its  proper  function  just  as  well  as  if  it  were  half  the  size.  Stasis  of 
food  of  over  ten  hours'  duration  indicates  always,  in  my  view,  a  pathologic  condition. 
If  stasis  is  of  long  duration  as  the  result  of  obstruction,  then  hypertrophy  of  the 
muscular  coats  of  the  stomach,  more  especially  in  the  pyloric  half,  is  noticed.  In 
a  well-marked  case  of  this  kind  constant  waves  of  contraction  can  be  seen  to  pass 
from  left  to  right  across  the  front  of  the  abdomen;  and  inflation  with  CO  2  will  often 
elicit  these  when  otherwise  they  are  not  evident.     In  long-standing  cases  of  pyloric 


326  OPEEATIOXS  UPON  THE  STOMACH. 

obstruction  the  patient  may  vomit,  after  three  or  four  days,  food  which  has  lain 
stagnant  all  that  time  in  the  stomach. 

Indications  for  the  Performance  of  Gastro-enterostomy.— (A)  The  fol- 
lowing are  the  conditions  in  cases  of  gastric  ulcer  wliich  call  for  treatment  by  gastro- 
enterostomy: 

1.  ^Mien  perforation  has  occurred  in  an  ulcer  so  situated  that  the  closure  of  the 
opening  narrows  the  outlet  of  the  stomach,  e.  g.,  in  pyloric  ulcer  or  in  duodenal. 

2.  "\Mien  -perforation  has  occurred  in  an  ulcer  in  the  stomach  and  a  second  ulcer 
near  the  pylorus  or  in  the  duodenum  is  seen.  (In  one  of  my  cases  death  occurred 
from  the  perforation  of  a  duodenal  ulcer  eleven  days  after  the  closure  of  a  gastric 
perforation.) 

3.  When  hemorrhage  is  occurring  from  a  duodenal  or  gastric  ulcer  in  such  quan- 
tities as  to  threaten  the  life  of  the  patient.  In  such  circumstances  the  hemorrhage 
usually  occurs  in  increasing  quantity  at  decreasing  intervals. 

4.  When  inveterate  dyspepsia  is  caused  by  a  chronic  ulcer  of  the  stomach  which 
medical  treatment  has  not  sufficed  to  heal. 

5.  When  an  inflammatory  tumor  of  the  stomach  or  pylorus  results  from  the 
induration  and  tliickening  around  an  ulcer. 

5.  When  perigastritis  with  adhesions  secondary  to  ulcer  or  other  complications 
(cholecysto-gastric  or  duodenal  fistula)  is  interfering  with  the  proper  action  of  the 
stomach. 

7.  When  an  ulcer  in  its  cicatrization  has  caused  a  narromng  in  the  body  of  the 
stomach  (hour-glass  stomach)  or  at  the  pylorus  (pyloric  stenosis),  with  consecutive 
dilatation  and  hypertrophy  of  the  stomach  behind  the  obstruction,  and  stasis  of  the 
stomach  contents. 

8.  When  a  duodenal  ulcer  has  been  diagnosed  with  certainty,  and  its  symptoms 
have  not  rapidly  receded  under  treatment.  ^Medical  treatment  is  of  extremely  little 
value  in  cases  of  duodenal  ulcer,  owing  to  the  mechanical  conditions  present. 
Personally  I  advise  surgical  treatment  for  duodenal  ulcer  as  soon  as  the  diagnosis  is 
assured. 

(B)  In  cases  of  corrosion  of  the  gastric  mucosa  by  acids  or  alkalis,  or  other  irri- 
tants.— When  an  acid  or  an  alkali,  carbolic  acid,  soap  lyes,  or  the  like,  are  swallowed 
by  accident  or  with  suicidal  intent  the  stress  of  the  caustic  efi^ect  may  fafi  upon  the 
mouth,  pharynx,  esophagus,  or  stomach.  If  the  stomach  is  chiefiy  aftected  it  is 
always  the  pyloric  portion  which  suffers  most.  The  mucous  membrane  there  is 
then  thin,  purple,  and  easily  stripped  away.  From  the  outside  the  pyloric  portion 
of  the  stomach  resembles  a  solid  cylinder,  being  hard,  contracted,  and  inexpansile. 
The  symptoms  produced  by  this  condition  are  pain  on  any  attempt  at  feeding,  and 
incessant  vomiting.  In  such  circumstances  gastro-enterostomy  alone  may  be  per- 
formed, or,  as  is  better,  gastro-enterostomy  combined  with  gastrostomy,  a  tube  being 
passed  into  the  distal  limb  of  the  jejunum,  and  the  patient  being  fed  entirely  through 
this  for  a  few  weeks. 


GASTRO-ENTEROSTOMY.  327 

(C)  In  Cases  of  Congenital  {or  Infantile)  Hypertrophic  Stenosis  of  the  Pylorus. — 
In  the  year  1788,  as  Osier  ^  has  reminded  us,  Beardsley,  of  New  Haven,  Con- 
necticut, described  the  first  case  ever  observed  of  this  disease.  He  wrote:  "The 
pylorus  was  invested  with  a  hard  compact  substance  or  scirrhosity  which  so  com- 
pletely obstructed  the  passage  into  the  duodenum  as  to  admit  with  the  greatest 
difficulty  the  finest  probe. "  In  1841  Williamson^  recorded  the  second  case,  which 
occurred  in  a  child  who  died  at  the  age  of  five  weeks.  In  1842  Dawosky^  related  a 
third  case.  It  was  not,  however,  till  Hirschsprung*  recorded  two  cases  that  renewed 
attention  was  called  to  the  disease.  In  recent  years  Thomson,^  and  Cautley  and 
Dent®  have  made  important  contributions  to  our  knowledge. 

The  symptoms  are  these :  A  child,  normal  at  birth,  within  a  few  days,  as  a  rule, 
but  sometimes  not  till  the  lapse  of  a  few  weeks,  begins  to  vomit,  in  quantities  which 
gradually  increase;  the  act  of  vomiting  is  forcible,  food  being  ejected  two  or  three 
feet  from  the  patient.  Little  by  little  loss  of  flesh  is  remarked,  until  the  child  becomes 
wasted  to  an  extreme  degree.  Constipation  is  always  present,  and  is  due  to  an 
absence  of  food  in  proper  quantity  in  the  stomach.  When  the  abdomen  is  exam- 
ined a  dilated  and  contracting  stomach  can  often  be  seen,  and  a  tumor  can  be  felt 
at  the  pylorus.  It  is  this  tumor  which  is  the  cause  of  the  stenosis  at  the  outlet  of 
the  stomach.  When  examined  it  is  found  to  be  firm,  cylindric,  solid.  On  inspec- 
tion from  the  duodenal  side  the  mass  projects  into  the  lumen  of  the  bowel,  presenting 
an  appearance  constantly  likened  to  that  of  the  cervix  uteri.  The  tumor  is  due  to  a 
hyperplasia  of  the  circular  muscular  fibers.  In  rare  cases  there  has  been  a  hyper- 
trophy of  the  longitudinal  fibers  also;  in  all  cases  there  are  numerous  long  folds 
of  mucous  membrane.     The  etiology  of  this  disease  is  obscure. 

Various  forms  of  operative  treatment  have  been  suggested :  pylorectomy,  pyloro- 
plasty, and  gastro-enterostomy..  The  latter  is  perhaps  the  most  satisfactory  of  all 
methods,  though  pyloroplasty  in  the  hands  of  Clinton  Dent  has  yielded  admirable 
results.  The  medicinal  treatment  of  this  condition,  however,  is  not  to  be  neglected. 
There  is  good  evidence  to  show  that  by  careful  attention  to  the  details  of  medical 
treatment,  careful  dieting,  and  gastric  lavage,  surgical  treatment  is  very  rarely 
necessary.'' 

According  to  Scudder  and  Quinby,^  gastro-enterostomy  has  been  performed 

1  Osier,  Wm.:  Address:  "On  the  Educational  Value  of  the  Med.  Society,"  Bost.  Med.  and 
Surg.  Jour.,  March  12,  1903,  cxlviii,  No.  11,  p.  275. 

^  Williamson,  Thomas:  "Case  of  Scirrhus  of  the  Stomach,  Probably  Congenital;  with  Re- 
marks," London  and  Edinburgh  Monthly  Jour,  of  Med.  Sci.,  Jan.,  1841,  No.  1,  p.  23. 

^  Dawosky,  Simon:  "Alteration  de  I'estomac  chez  un  nouveau-ne,"  Arch.  Gen.  de  Med., 
Mai,  1843,  4e  Serie,  Tome  ii,  p.  93. 

*  Hirschsprung:  "Falle  von  angeborener  Pylorusstenose,  beobachtet  bei  Sauglingen,"  Jahrb. 
f.  Kinderheilk.,  N.  F.,  1888,  xxviii,  61. 

^Thomson,  John:  "On  Congenital  Spasm  (Congenital  Hypertrophy  and  Stenosis  of  the 
Pylorus),"  Scottish  Med.  and  Surg.  Jour.,  1897,  i,  511. 

'  Cautley,  E.,  and  Dent,  C.  T.:  "Congenital  Hypertrophic  Stenosis  of  the  Pylorus,"  Trans. 
Roy.  Med.  Chir.  Soc,  bcxxvi  (second  series,  Ixviii),  1903,  471. 

'  Still,  Geo.  F.:  "On  the  Diagnosis  and  Treatment  of  Hypertrophy  of  the  Pylorus  in  Infants," 
Lancet,  March  11,  1905,  i,  632.  Sutherland,  G.  A.:  "The  Medical  Treatment  of  Congenital 
Pyloric  Stenosis,"  Lancet,  Mar.  16,  1907,  p.  725. 

*  Scudder,  Charles  L.,  and  Quinby,  Wm.  C:  "Stenosis  of  the  Pylorus  in  Infancy,"  Jour. 
Amer.  Med.  Assoc,  1905,  xliv,  1665. 


328  OPERATIONS  UPON  THE  STOMACH. 

forty  times,  with  twenty-one  recoveries.  The  first  successful  case  was  performed 
on  a  child  ten  weeks  old,  in  July,  1898.  The  patient  at  the  age  of  six  was  "quite 
well  and  fully  developed  both  bodily  and  mentally."^  The  first  four  successful 
cases  are  still  alive  and  well  (Paterson).  A  very  interesting  discussion  upon  this 
subject  is  published  in  the  "  British  Medical  Journal, "  1906,  ii,  939.  In  performing 
these  operations  upon  such  small  cliildren  it  is  important  not  to  make  a  larger  in- 
cision than  is  really  necessary, — two  inches  is  ample,  as  a  rule, — and  to  take  pains  to 
suture  the  abdominal  wound  carefully  by  through-and-through  sutures  of  silkworm- 
gut  or  silver  wire. 

(D)  In  Carcinoma  of  the  Pyloric  Part  of  the  Stomach  or  of  the  Duodenum. — The 
role  of  gastro-enterostomy  in  cases  of  cancer  of  the  stomach  is  one  about  which  all 
surgeons  are  not  agreed.  The  indication  upon  which  I  act  is  this:  if  the  growth  is 
causing  any  obstruction  to  the  onward  passage  of  food,  or  if  the  growth  in  its  increase 
seems  likely  to  obstruct,  then  a  short-circuiting  operation  is  indicated.  But  this 
indication  holds  good  only  when  the  extent  of  the  disease,  or  the  presence  of  secon- 
dary deposits  in  the  liver  or  elsewhere,  or  the  firm  adhesion  of  the  growth  to  the  pan- 
creas or  other  part,  makes  the  removal  of  the  growth  impossible;  or  when  though 
the  growth  is  removable  the  condition  of  the  patient  is  such  that  an  operation  of  this 
character  would  almost  certainly  be  fatal.  In  cases  of  cancer  of  the  stomach  gas- 
trectomy should  be  performed  if  possible;  but  unhappily  the  number  of  cases  in 
which  this  can  be  done  is  comparatively  small.  There  are  not  a  few  patients  who 
are  so  terribly  emaciated,  though  the  disease  has  not  passed  beyond  the  stomach 
itself,  that  a  removal  of  the  growth  would  be  fatal,  almost  certainly.  In  such  in- 
stances gastro-enterostomy  may  be  performed  first,  the  anastomosis  being  made 
wide  of  the  disease,  and  the  patient  fed  while  on  the  table  through  a  stomach-tube 
passed  from  the  stomach  by  the  new  opening  into  the  jejunum.  Two  or  more  pints 
of  peptonized  milk  are  given  in  this  way,  and  the  patient  may  then  be  invigorated 
sufficiently  to  allow  the  gastrectomy  to  be  performed  at  once.  Or  the  major  opera- 
tion may  be  postponed  for  three  weeks;  during  this  time  food  may  be  taken  in 
abundance,  and  a  gain  in  weight  of  almost  a  pound  a  day  recorded.  I  have  never, 
personally,  found  any  difficulty  in  then  persuading  a  patient  to  undergo  the 
more  serious  operation  of  removal  of  the  growth. 

It  is  no  less  important  to  state  the  contraindications  of  gastro-enterostomy. 
This  operation  is  of  no  value  in  cases  of  atonic  dilatation  of  the  stomach;  it  gives 
no  relief  to  those  who  suffer  from  "sensitive  stomachs,"  the  nervous  dyspeptic 
women,  or  the  hypochondriacs;  it  does  not  lessen  the  discomforts  due  to  prolapse  of 
the  stomach.  It  is  of  value  only  in  cases  of  organic  disease;  the  patient  who  suffers 
from  "functional  dyspepsia"  is  not  a  proper  patient  for  surgical  treatment. 

I  have  occasionally  been  asked  to  operate  upon  patients,  always  of  the  female 

sex,  who  have  made  long  and  piteous  complaints  of  stomach  troubles.     Such  cases 

are  perhaps  handed  over  for  operation  after  several  "cures"  by  medical  treatment. 

When  the  abdomen  is  opened,  no  organic  lesion  of  any  kind  is  discoverable,  neither 

1  Paterson,  H.  J.:    "Gastric  Surgery,"  1906,  p.  92. 


THE    OPERATION    OF    GASTRO-EXTEROSTOMY.  329 

in  the  alimentary  tract  (stomach,  duodenum,  appendix)  nor  in  the  gall-bladder. 
In  such  cases  there  is  no  indication  for  the  operation  of  gastro-enterostomv.  Its 
performance  in  these  circumstances  can  only  bring  discredit  on  the  operation.  I 
do  not  believe  in  gastro-enterostomy  for  the  relief  of  symptoms  dependent  upon 
no  visible  disease.  And  I  frankly  disbelieve  in  the  ulcer  of  the  stomach  or  duodenum 
that  cannot  be  seen  or  felt,  and  demonstrated  to  the  onlooker.  Invisible  and  im- 
palpable gastric  ulcers,  as  a  cause  of  symptoms,  are  a  myth. 


THE  OPERATION  OF  GASTRO-ENTEROSTOMY. 

Preparation  of  the  Patient. — No  insignificant  part  of  the  success  of  this  opera- 
tion, or  of  any  of  the  operations  upon  the  stomach,  depends  upon  the  details  of  the 
preparation  of  the  patient  in  the  few  days  preceding  the  actual  operation.  The 
chief  of  the  details  of  preparation  is  concerned  with  the  attempt  to  render  sterile 
the  mouth,  the  stomach,  and  the  jejunum.  In  a  very  large  proportion  of  the  pa- 
tients who  come  to  operation  for  chronic  ulcer  of  the  stomach  or  duodenum  a  very 
defective  condition  of  the  teeth  is  noticeable;  and  it  is  by  no  means  improbable 
that  the  septic  material  from  such  teeth,  swallowed  constantly  by  the  patient,  is  an 
important  factor  in  the  causation  of  the  ulcer.  The  most  scrupulous  attention  to 
the  toilet  of  the  mouth  must  be  started  as  soon  as  the  patient  is  admitted  to  the  hos- 
pital. If  the  teeth  are  very  bad,  it  may  be  necessary  to  have  one  or  more  extracted, 
and  others  stopped.  The  patient  should  be  told  to  brush  the  teeth  with  some  frag- 
rant antiseptic  wash  very  frec}uently.  The  nurse  is  instructed  to  see  that  such 
attentions  are  satisfactory.  All  nourishment  given  l^efore  the  operation  should  be 
fluid  and  sterile.  An  aperient  is  given  a  few  days  before  the  operation,  and  an 
enema  or  two,  or  more,  may  be  necessary  to  secure  the  complete  emptying  of  the 
large  intestine. 

Many  patients  who  have  chronic  gastric  disease  suffer  from  constipation,  and 
it  is  no  easy  matter  then  to  get  the  large  intestine  empty  of  all  scybalous  masses.  To 
do  so,  however,  is  important,  for  the  comfort  of  the  patient  is  thereby  greatly  in- 
creased for  the  few  days  subsequent  to  the  operation.  The  stomach  is  washed  out 
as  often  as  is  necessary  to  insure  its  cleanliness.  In  ordinary  cases  once  or  twice 
is  sufficient,  but  there  are  cases  of  greatly  dilated  stomach  in  which  the  food  has 
been  stagnant  which  are  not  to  be  cleansed  so  easily.  The  lavage  should  be  copious, 
hot  saline  solution  being  used.  It  is  only  when  hemorrhage  has  recently  occurred 
that  great  care  is  necessary  in  the  process ;  if  there  has  been  recent  severe  hemorrhage 
I  do  not  wash  the  stomach  out  at  all,  or  do  so  only  very  gently,  just  before  the  opera- 
tion. In  cases  where  the  stomach  is  very  foul,  it  is  useful  to  administer  isoform  in 
dose  of  S  grains  thrice  daily. 

The  following  methods  of  gastro-enterostomy  will  be  described :  (A)  Posterior 
gastro-enterostomy;    (B)    anterior  gastro-enterostomy;    (C)    Roux's  operation. 

Posterior  Gastro-enterostomy. — Tcchnic  of  the  Operation. — An  incision 
about  4  to  5  inches  in  length  is  made  three-fourths  of  an  inch  to  the  right  of  the 


330 


OPERATIOXS    UPON   THE    STOMACH. 


middle  line,  and  the  anterior  sheath  of  the  rectus  opened.  The  fibers  of  the  rectus 
muscle  are  then  spht  from  top  to  bottom,  by  first  gently  separating  them  at  the 
tendinous  intersection  toward  the  upper  end  of  the  wound,  and  then  extending  this 
separation  downward.  A  vessel  to  the  lower  end  of  the  wound,  a  Uttle  above  the 
umbilicus,  may  require  a  Hgature.  The  posterior  sheath  of  the  rectus  and  the  peri- 
toneum are  incised  together  and  the  abdominal  ca%dty  opened.  As  soon  as  this  is 
done  a  sterihzed  cloth  or  handkerchief  (the  "tetra"  material  is  the  best)  is  appHed 
on  each  side  of  the  wound  and  cKpped  above  and  below  so  that  the  skin  is  neither 
seen  nor  touched  in  any  of  the  subsecjuent  manipulations.  A  general  inspection 
of  the  stomach,  duodenum,  and  gall-bladder  is  first  made,  and  if  the  patient  is  tliin 
and  well -anesthetized  there  is  no  difficulty  in  this.     The  presence  of  ulcer,  adhesion, 

growth,  etc.,  is  noticed, 
the  position  of  parts,  and 
their  mutual  relationships. 
The  hand  is  then  passed 
into  the  wound  and  a  very 
careful  examination  made 
of  the  whole  of  the  stom- 
ach from  cardia  to  duo- 
denum. The  need  for  this 
advice  is  illustrated  by  the 
not  infrequent  cases  where 
hour-glass  stomach  has 
been  overlooked.  I  have 
recently  operated  upon  a 
man  whose  abdomen  had 
been  opened  by  a  most  dis- 
tinguished surgeon  three 
months  before,  and  closed 
again,  as  there  was  "noth- 
ing wrong  with  the  stom- 
ach. "  This  was  true,  but 
there  was  a  large  duodenal 
ulcer  with  a  cystoduodenal  fistula  which  had  been  overlooked.  The  inspection 
and  the  manual  examination  must  be  done  thoroughly,  but  quickly.  When  it 
has  been  decided  to  perform  gastro-enterostomy,  the  great  omentum  and  the 
transverse  colon  are  turned  upward  out  of  the  wound,  until  the  under  surface 
of  the  transverse  mesocolon  is  exposed.  At  this  stage,  before  anything  further  is 
touched,  the  surgeon  must  inspect  the  duodenojejunal  fiexure  in  order  to  see  the 
direction  which  is  taken  by  the  first  few  inches  of  the  jejunum  as  it  leaves  the  flexure. 
It  will  be  found  that  this  varies  considerably.  In  rather  more  than  half  the  cases 
(as  my  figures  show  at  present)  the  jejunum  passes  outward  to  the  left,  along  the 
lower  border  of  the  pancreas,  horizontally  or  slightly  downward  to  the  hollow  below 


Fig,  564. — Showixg  Jejunum  Going  to  the  Left. 


THE    OPERATION    OF   GASTRO-EXTEROSTOilY, 


331 


the  kidney  (Fig.  564).  In 
other  cases  the  gut  passes 
almost  vertically  down- 
ward (Fig.  565) ;  in  still 
other  cases  downward  and 
to  the  right  in  the  direc- 
tion of  the  appendix  (Fig. 
566).  AMiatever  the  di- 
rection is,  it  must  be  care- 
fully and  accurately  noted, 
for  the  intention  is  that 
the  natural  direction  of  the 
jejunum  should  remain 
after  the  completion  of  the 
anastomosis.  For  example, 
it  is  not  desirable,  when 
the  jejunum  passes  to  the 
left,  that  it  should  be  fixed 
along  a  line  on  the  stom- 
ach drawn  downward  and 


Fig.  565. — Showing  Jejunum  Descending  Vertic.a 


to    the 
equally 


L^>,«^« 


right,    and    it    is 

undesirable  that  a  jejunum  whose  direction  is  toward  the  appendix  should 

be  attached  to  the  stomach 
along  a  line  drawn  down- 
ward and  to  the  left.  One 
of  these  faults  is  as  serious 
as  the  other. 

The  jejunal  direction 
being  carefully  noted,  the 
transverse  mesocolon  is 
divided  at  a  spot  devoid 
of  vessels  close  to  the 
duodenojejunal  flexure. 
The  opening  so  made  into 
the  lesser  sac  of  the  peri- 
toneum is  rapidly  enlarged 
to  a  sufficient  degree,  and 
the  posterior  surface  of  the 
stomach  thus  exposed  is 
drawn  through  the  open- 
ing (Fig.  567).  It  is  im- 
portant to  select  the  proper 

Fig.  566.— Showing  Jejunum  Going  to  the  Right.  part  of  the  StOUiach  for  thc 


> 


332 


OPERATIONS  UPON  THE  STOMACH. 


anastomosis.  This  is  approximately  at  the  junction  of  the  cardiac  two-thirds  with 
the  pyloric  tliird,  at  the  most  dependent  part  of  the  greater  curvature.  The  next 
step  is  to  determine  the  direction  of  the  line  on  the  stomach  along  which  the  anas- 
tomosis w^ith  the  jejunum  has  to  be  made.  If  the  jejunum  has  been  found  to  pass 
to  the  left  along  the  lower  border  of  the  pancreas,  the  line  upon  the  stomach  should 
run  obliquely  from  above  downward  and  to  the  left;  the  line,  that  is  to  say,  corre- 
sponds with  that  of  the  normal  direction  of  the  jejunum.     If  the  jejunum  has  been 


Fig.  567. — Posterior  Gastro-enterostomy;    Opening  in  Mesocolon. 


found  to  pass  downward  and  to  the  riglit  toward  the  appendix,  then  the  line  upon 
the  stomach  should  run  obliquely  from  above  downward  and  to  the  right.  Be- 
tween these  two  extremes  any  direction  may  be  taken  upon  the  stomach  to  corre- 
spond with  the  jejunal  line. 

As  soon  as  the  direction  of  the  line  of  anastomo.sis  has  been  determined  upon,  a 
clamp  is  applied  to  the  stomach  in  such  manner  as  to  make  sure  that  this  line  is  em- 
braced by  the  clamp.  A  second  clamp  is  then  applied  to  the  jejunum  as  high  up  as 
possible,  so  that  when  the  operation  is  completed  the  opening  between  the  jejunum 


THE    OPERATION    OF   GASTRO-ENTEROSTOMY. 


333 


and  the  stomach  shall  begin  about  Ih  inches  below  the  duodenojejunal  flexure. 
In  place  of  the  two  clamps  I  now  generally  use  a  single  three-bladed  clamp  (Fig. 
568),  which  is,  on  the  whole,  rather  more  convenient.  The  original  three-bladed 
clamp  was  suggested  by  Roosevelt,  and  it  is  after  his  model  that  my  instrument 
was  made. 

All  the  viscera  except  those  parts  of  the  stomach  and  jejunum  engaged  in  the 
clamp  are  returned  within  the  abdomen  and 
covered  with  hot  moist  swabs.  The  swabs  are 
packed  closely  around  the  clamp  on  all  sides. 
The  sutures  are  now  introduced.  There  is  an 
outer  sero-muscular  suture  of  fine  linen  thread, 
and  an  inner  suture  which  includes  all  the  coats 
of  both  viscera,  also  of  Hnen  thread,  or,  if  it  is 
preferred,  of  catgut.  The  outer  suture  is  first 
introduced.  It  commences  at  the  part  of  the 
stomach  and  intestine  furthest  from  the  oper- 
ator, and  is  carried  toward  him  for  a  distance 
of  2h  inches  at  least,  until  the  end  of  the  clamp 
nearest  him  is  reached.  The  interval  between 
the  individual  insertions  of  this  continuous 
suture  are  about  one-eighth  of  an  inch  and  the 
stitch  all  along  is  pulled  fairly  tight  (Fig.  569). 
As  each  passage  of  the  needle  through  jejunum 
and  stomach  is  completed  the  suture  is  pulled 
upon  gently,  so  that,  at  the  same  time,  the 
thread  just  introduced  is  tightened  and  a  little 
ridge  or  fold  of  each  viscus  is  raised  up,  making 
clear  the  exact  position  for  the  passage  of  the 
needle  next  time.  When  the  first  row  of  the 
stitch  is  complete,  the  needle  is  laid  aside,  to  be 
used  again  at  a  later  stage  of  the  operation. 
In  front  of  this  row  an  incision  is  now  made 
into  the  stomach  and  jejunum,  the  serous  and 
muscular  layers  of  each  being  carefully  divided 
until  the  mucous  membrane  is  reached.  As  the 
cut  is  made  the  serous  coat  retracts  and  mucous 
layer  pouts  into  the  incision.     The  cut  edge  of 

the  serous  coat  is  loosened  all  around  from  the  underlying  mucosa.  An  ellipse  of 
the  mucous  membrane  is  now  excised  from  both  stomach  and  jejunum,  the  por- 
tion removed  being  about  Ij  to  22  inches  in  length,  and  rather  more  than  half 
an  inch  in  breadth  at  the  center.  The  gastric  mucosa  shows  a  marked  tendency 
to  retract;  it  is,  therefore,  seized  with  a  pair  of  miniature  (French)  vulsella  forceps 
on  each  side.     No  vessels  are  ligated,  as  a  rule.     The  cut  surface  of  the  bowel  and 


Fig.  568. — Moynihan's  Modification   of 
Roosevelt's  Clamp. 


334 


OPERATIONS    UPON   THE   STOMACH. 


stomach  may  occasionally  ooze  slightly;  this  can  be  checked  at  once  by  tightening 
the  clamps  one  notch.  An  Allis  forceps  is  placed  on  the  posterior  cut  edges 
of  the  incision,  picking  up  the  mucous  and  serous  coats  of  the  stomach  and 
jejunum.  It  is  placed  at  or  near  the  end  of  the  incision,  near  the  operator, 
and  is  allowed  to  hang  down.  Its  weight  is  sufficient  to  keep  the  cut  edges 
now  to  be  sutured  in  apposition  and  to  make  them  fairly  taut.  The  inner  suture 
is  now  introduced.  It  embraces  all  the  coats  of  the  stomach  and  jejunum  around 
the  whole  circumference  of  the  opening.     The  needle  is  first  passed  through  the 

wall  of  the  jejunum,  from 
the  mucous  to  the  serous 
surface  at  the  left  end  of  the 
incisions,  and  then  from  the 
serous  to  the  mucous  surface 
of  the  stomach  at  a  corre- 
sponding point;  the  knot, 
when  tied,  is  on  the  mucous 
surface.  The  needle  is  now 
passed,  time  after  time,  from 
the  mucosa  of  the  jejunum  to 
the  mucosa  of  the  stomach, 
picking  up  both  serous  coats 
in  its  passage.  The  stitch  is 
drawn  tight  enough  to  con- 
strict any  vessels  in  the  cut 
edges,  and  as  it  is  so  drawn 
the  point  for  the  next  intro- 
duction of  the  needle  is  made 
clear  (Fig.  570).  When  the 
stitch  has  been  completed 
along  the  hinder  margin  of 
the  incision,  it  is  returned 
along  the  anterior  margin 
(Fig.  571),  without  interrup- 
tion until  the  original  end 
of  the  stitch,  left  long,  is 
ends    of    the    suture    are    cut 


I-I  ^eckex- 


FlG.  569  I'OSTtRIOR  (j\SIRO-I  N  I  I  ROSTOV!^ 

Posterior  row  of  outer  sutures  introduced,  stomach  being  incised. 


reached,    when    a    triple    knot   is    tied,    and    the 
short. 

The  clamps  are  now  removed  from  both  stomach  and  jejunum;  the  parts  are 
wiped  over  with  hot  moist  swabs,  and  all  instruments  used  up  to  this  point  are 
discarded.  This  is  done  on  the  assumption  that  the  mucous  membranes  of  the 
two  viscera  may  contain  micro-organisms.  As  a  matter  of  fact,  organisms  are  almost 
invariably  absent,  if  the  plan  of  preparation  of  the  patient,  elsewhere  described,  is 
followed. 


THE    OPERATION    OF   GASTRO-ENTEROSTOMY. 


335 


The  original  serous  suture  is  now  continued  (Fig.  572).  The  needle  which  was 
laid  aside  is  used  again.  The  only  difficult  part  of  the  stitch  is  now  encountered, 
for  there  are  many  vessels  along  the  greater  curvature  of  the  stomach  and 
near  it  which  have  to  be  avoided,  and  unless  the  utmost  exactness  is  observed, 
a  vessel  may  easily  be  wounded.  If  it  should  be,  a  deeper  and  wider  stitch  must 
be  passed,  and  tied  with  sufficient  firmness  to  check  the  bleeding.  The  suture  is 
drawn  upon  with  moderate  firmness,  with  the  result  that  the  place  for  the  next 
introduction  of  the  needle  is  made  plain.  When  the  stitch  has  been  carried 
aneund  to  the  point  from  which  it 
originally  started,  the  end  of  the 
thread  left  long  is  taken  in  the 
fingers;  with  it  the  stomach  and 
jejunum  are  dragged  gently  up- 
ward, and  beyond  it  the  needle  is 
passed  once  before  being  tied. 

The  stomach  and  jejunum  are 
now  gently  wiped  over  with  a  hot 
moist  swab,  and  the  swabs  packed 
round  the  gut  are  removed.  All 
that  remains  to  be  done  now  is  to 
suture  the  edges  of  the  opening  in 
the  transverse  mesocolon  to  the 
bowel.  This  is  done  by  pulling 
gently  on  the  jejunum  and  the 
stomach,  and  attaching  a  clip  to 
the  cut  edge  of  the  mesocolon,  so 
as  to  insure  that  accurate  apposi- 
tion is  obtained.  A  needle  then 
picks  up  the  mesocolon  a  little  from 
the  cut  edge,  and  is  then  passed 
through  the  stomach  and  jejunum 
at  the  line  of  the  anastomosis. 
When  the  suture  it  carries  is  tied 
the  cut  edge  of  the  mesocolon  will 

be  rolled  inward  toward  the  lesser  sac,  so  that  only  a  smooth  edge  is  left  at  the 
suture  line  (Fig.  573).  Three  or  more  similar  sutures  are  passed  on  the  other 
side  of  the  anastomosis  and  below  it,  and  the  gut  wiped  and  returned  within  the 
abdomen.  If  a  pyloric  or  duodenal  ulcer  has  been  exposed,  it  is  wiser  to  infold  it, 
so  as  to  prevent  any  chance  of  hemorrhage,  and  to  secure  the  more  rapid  healing  of 
the  ulcer. 

The  abdominal  wall   is    then   closed,  layer  by  layer,  by  suture  in  the  usual 
manner. 

After-treatment. — As  soon  as  the  patient  is  returned  to  bed  he  is  propped  up 


■inner  i: uiure- 


\£/.  IBec^ex: 


Fig.  670. — Posterior  GASTuo-E.\TLKot^Tu.Mv. 
Porterior  row  of  inner  through-and-through  sutures  intro- 
duced. 


336 


OPERATIONS    UPON   THE    STOMACH. 


almost  in  a  sitting  position  with  a  bed-rest  or  five  pillows.  This  position  is  some- 
times difficult  to  continue,  because  the  patient  shows  a  persistent  tendency  to  shp 
down  in  the  bed.  A  pillow  is  placed  beneath  the  knees;  or  a  special  cushion, 
suggested  by  Cairns  Forsyth,  wliich  is  placed  beneath  the  tliighs  and  tied  by  a 
strong  tape  at  each  end  to  the  head  of  the  bed,  wiU  be  found  useful. 

As  a  rule,  the  patient  does  not  vomit  at  all,  or  if  in  the  act  of  vomiting  the  stom- 
ach is  emptied  it  is  through  the  new  opening  into  the  jejunum  that  the  fluids  pass 
and  not  out  of  the  esophagus.     These  patients  vomit  less  than  those  operated  upon 

for  any  other  abdominal  com- 
plaint. For  two  or  three  hours 
notliing  is  given  by  the  mouth, 
but  an  occasional  flushing  of 
the  mouth  with  water  or  tea 
may  be  allowed.  When  the 
patient  desires  to  drink  he  is 
permitted  to  do  so,  a  cup  of 
tea  or  a  drink  of  water  being 
given.  There  is  no  stint  in  the 
quantity  of  fluids;  the  patient's 
desires  are  allowed  to  control 
the  supply  of  liquids  given. 
In  the  majority  of  cases  no 
sedative  is  necessary,  but  if  the 
patient  is  sufi^ering  pain,  a 
hypodermic  injection  of  |  gr.  of 
morphin  is  quite  sufficient  to 
afford  relief,  and  to  insure  a 
few  hours'  rest.  Whenever 
morphin  is  given  a  turpentine 
enema  is  administered  twelve 
hours  after,  for  otherwise  flatu- 
lence may  be  troublesome.  For 
a  week  notliing  but  fluids  are 
allowed;  then  milk  puddings, 
custard,  bread  and  butter,  etc.  I  never  persuade  a  patient  to  take  soHd  food, 
waiting  always  until  he  complains  of  an  unsatisfied  appetite.  Throughout,  a  very 
careful  toilet  of  the  mouth  is  observed,  and  a  simple  aperient  enema  is  given 
every  twenty-four  hours.  On  the  eighth  day  the  patient  is  allowed  to  sit  up,  after 
the  wound  has  healed,  but  before  the  deep  stitches  are  removed.  These  are  taken 
out  about  the  twelfth  day. 

(B)  Anterior  Gastro-enterostomy. — In  certain  exceptional  cases  it  is  neces- 
sary to  perform  the  anterior  operation.  The  indications  for  the  preference  of  the 
anterior  method  are:    the  existence  of  adhesions  between  the  posterior  surface  of 


Fig.  571. — Posterior  Gastro-enterostomy. 
Inner  row  of  sutures  continued  around  the  opening. 


THE    OPERATION    OF   GASTRO-ENTEROSTOMY, 


337 


the  stomach  and  the  pancreas,  [K-  '•'  ''''''•" 
the  invasion  by  growth  of  the 
posterior  surface  or  of  the  trans- 
verse mesocolon,  shortness  of  the 
mesocolon,  etc.  There  are  many 
surgeons  who  prefer  the  anterior 
operation  in  all  cases  of  carcin- 
oma, but  I  personally  prefer  the 
posterior  method  in  all  cases 
where  it  is  mechanically  possi- 
ble. 

The  abdomen  is  opened  in 
the  manner  described  above 
through  the  right  rectus  muscle. 
As  soOn  as  the  stomach  is  ex- 
posed, the  anterior  wall  of  it  is 
gripped  in  a  clamp,  in  such 
manner  that  the  fold  so  inclosed 
runs  obliquely  on  the  surface  of 
the  stomach  from  the  lowest 
point  on  the  greater  curvature 
upward  and  to  the  left  toward 
the  fundus  of  the  stomach  and 
the  cardia.      A  good  fold,   at  least  three  inches  in  length,  is  so  grasped. 


jti.:\BecJ<:_eT: 


Pig.  572.- 


-POSTKRIOR  GaSTHO-ENTEROSTOMT. 

Serous  suture  continued. 


.;a\ 


) 


t    f 


^ 


VVv  j'ost  surface 
^\^Stornach 

V' 


>^ 


l^f 


Fig.  573. — I'osn.iuoR  Gastro-entkrosto.my, 
Suturing  the  mesocolon  to  anastomosis. 

VOL.  II — 22 


The  jejunum  is  then 
sought,  by  lifting  up 
the  transverse  'colon 
and  the  omentum  and 
defining  the  upper- 
most part  at  the  du- 
odenojejunal flexure. 
A  point  about  15  to  18 
inches  below  the  flex- 
ure is  then  embraced 
in  a  secontl  clamp,  or 
in  the  other  half  of  a 
three  -  bladed  clamp. 
The  two  clamps  are 
then  placed  side  by 
side  in  such  manner 
that  the  highest  part 
of  the  stomach  fold  is 
applied  to  the  highest 
part  of  the  jejunum. 


338 


OPERATIONS   UPON   THE    STOMACH, 


The  viscera  are  now  surrounded  with  gauze,  as  in  the  posterior  operation,  and 
the  sutures  are  inserted.  The  method  of  their  introduction  is  precisely  the  same 
as  in  the  posterior  operation,  except  that  the  outer  layer  is  made  to  inclose  a  longer 
area  than  the  inner,  so  that  at  the  upper  end  of  the  apposed  surfaces  there  is  no 
opening.  When  the  jejunum  is  fixed  to  the  stomach  it  is  desirable  to  make  its 
attachment  extend  well  above  the  opening,  so  that  there  is  no  likehhood  of  a  kink 
in  the  gut  at  the  upper  end.     This  is  simpler  and  more  certain  than  the  insertion 

of  suspension  sutures. 
The  outer  row  of  sutures 
extends  generally  over  a 
length  of  3  inches;  the 
opening,  2  inches  in 
length,  is  kept  to  the 
lower  end  (Fig.  574) . 

In  some  cases  of  an- 
terior gastro-enterostomy 
it  is  necessary  to  make 
an  entero  -  anastomosis 
between  the  afferent  and 
efferent  limbs  of  the 
jejunal  loop.  Many  sur- 
geons perform  this  as  a 
routine;  though  it  adds 
much  to  the  time  of  the 
operation  and  perhaps 
something  to  its  risk. 

(C)  Roux's  Opera- 
tion.— Roux,  of  Laus- 
anne, has  introduced  a 
most  ingenious  method 
of  gastro-enterostomy; 
the  gastro  -  enterostomy 
in  Y  he  calls  it,  which 
reproduces  as  nearly  as 
possible  the  normal  con- 
ditions in  the  duodenum. 
The  jejunum  high  up  is  divided  completely  across,  the  distal  end  is  inserted  into 
the  stomach,  and  the  proximal  end  into  the  side  of  the  distal  about  three  inches 
below  the  anastomosis.  The  new  opening  then  represents  the  pylorus,  and  the 
opening  of  the  proximal  limb  into  the  distal  represents  the  opening  of  the  common 
bile-duct  and  pancreatic  duct  into  the  duodenum.  Though  ideally  perfect,  this 
operation  in  practice  has  many  disadvantages,  the  chief  of  which  is  that  it  takes 
forty-five  minutes  to  perform,  as  there  are  two  anastomotic  openings  to  make. 


Fig.  574. — Anterior  Gastro-enterostomy. 

The  extension  of  the  outer  row  of  sutures  well  beyond  the  upper  limit  of  the 

opening  is  seen. 


THE   OPERATION    OF   GASTRO-ENTEROSTOMY. 


339 


The  operation  is  performed  in  the  f ohowing  way :  The  stomach-wall  is  clamped 
as  in  the  ordinary  operation.  A  long  loop  of  jejunum  is  then  picked  up,  and  its 
base  is  secured  by  a  clamp.  At  least  8  to  9  inches  should  be  the  length  of  the  loop 
whose  base  the  clamp  holds.  The  loop  embraced  by  the  clamp  is  now  divided  about 
2  inches  from  the  upper  clamped  end,  the  cut  being  extended  into  the  mesentery 
(Fig.  575).  The  upper  cut  end  of  the  jejunum  is  now  united  to  the  side  of  the 
lower  part,  just  above 
the  place  where  it  is 
clamped;  the  union  is 
effected  in  the  ordinary 
manner  by  suture.  The 
distal  cut  end  is  then 
united  to  the  stomach  as 
it  is  held  by  the  other 
clamp.  The  anastomo- 
ses are  both  completed 
before  either  clamp  is 
removed.  There  is  con- 
sequently no  soiling  of  the 
operation  field  by  gastric 
or  intestinal  discharges 
or  by  blood  (Fig.  576) . 

In  the  performance 
of  these  several  opera- 
tions many  surgeons  still 
use  the  Murphy  button, 
the  bone  bobbin,  the 
McGraw  elastic  ligature, 
etc.  Such  aids  to  sur- 
gery are  no  longer  neces- 
sary.    With  practice  the 

operation    is    periormed  p^^  575.— roux's  method  of  Gastro-enterostomy  in  y. 

as  quickly  without  them 

as  with  them.      From  every  point  of  view  their  use  at  the  present  day  is  to  be 

deprecated, 

COMPLICATIONS  FOLLOWING  GASTRO-ENTEROSTOMY. 
In  the  early  days  of  this  operation  the  complications  were  both  numerous  and 
serious,  but  in  recent  years  the  great  improvements  in  technic  have  made  our  strug- 
gle with  these  conditions  infrequent.  It  cannot,  however,  be  said,  even  now,  that 
the  operation  is  free  from  complications,  which  may  be  of  very  grave  import.  The 
following  are  the  most  important  of  these:  (1)  Hemorrhage.  (2)  Regurgitant 
vomiting.     (3)  Intestinal  obstruction.     (4)  Peptic  ulcer.     (5)  Diarrhea. 


jf_:3^P'^^^-'- 


340 


OPERATIONS    UPON    THE    STOMACH. 


Hemorrhage. — Hemorrhage  occurring  after  gastro-enterostomy  may  be  tri\'ial 
and  unimportant,  or  it  may  be  so  copious  as  to  be  the  cause  of  death.  In  the  very 
great  majority  of  cases  it  is  sUght  in  cjuantity,  a  few  mouthfuls  of  a  black  fluid  being 
vomited  within  one  hour  of  the  operation.  In  other  cases  it  is  more  abundant,  a 
pint  of  chocolate-colored  fluid  being  ejected  within  twenty-four  hours ;  in  yet  other 
cases  the  bleeding  may  be  abundant,  and  continuous  and  lethal.  The  blood  may 
come  from  an  ulcer  in  the  stomach  or  duodenum,  or  from  the  cut  edges  of  the  stom- 
ach or  jejunum  engaged  in  the  anastomosis.     In  a  few  recorded  cases  death  has 

occurred,  and  on  subse- 
quent examination  the 
blood  has  been  shown 
to  have  come  from  the 
wound  edges;  in  other 
cases  an  open  vessel  has 
been  found  in  the  base 
of  the  ulcer,  or  there  is 
e\adence  that  in  the 
handling  of  the  stomach 
during  the  operation  such 
damage  has  been  done 
as  to  set  up  hemorrhage. 
Hemorrhage  is  therefore 
a  preventable  complica- 
tion. It  will  not  occur 
from  the  wound  edges  in 
the  stomach  and  duo- 
denum if  the  parts  are 
carefully  sutured,  and  to 
insure  this,  certain  points 
must  be  observed.  These 
are:  the  use  of  a  con- 
tinuous suture,  not  of 
interrupted  sutures;    the 

Fig.  576.— Roux  Method  of  Gastro-exterostomy  in  Y.  inclusion   of   all    the  COatS 

in  the  inner  (hemostatic) 
suture;  the  firm  approximation  of  the  wound  edges  by  this  suture;  the  careful  in- 
spection of  the  suture  line  after  the  clamps  are  removed ;  the  picking-up  by  a  sep- 
arate stitch  of  any  point  from  which  blood  is  seen  to  come.  So  far  as  concerns  the 
ulcer  itself,  bleeding  is  prevented,  first,  by  the  gentle  handling  of  all  parts  during 
the  manipulations,  and  especially  during  the  time  that  the  clamps  are  appHed;  and, 
secondly,  by  the  careful  infolding  of  the  ulcer  in  the  manner  already  described. 

Regurgitant  Vomiting. — Of  all  the  distressing  comphcations  after  gastro- 
enterostomy this  is  the  worst.     Two  varieties  should  be  described:     (a)    An  ob- 


...-^iZ^^ 


COMPLICATIONS    FOLLOWING    GASTRO-ENTEROSTOMY.  341 

struction  variety  coming  on  early,  and  unless  relieved  causing  death,  (b)  An  inter- 
mittent form  coming  on  late,  and  being  little  more  than  an  occasional  distress. 

(a)  In  the  former  variety  vomiting  occurs  early,  is  copious  and  exhausting,  and 
often  proves  fatal.  In  the  early  days  of  the  operation  the  patients  literally  vomited 
themselves  to  death;  an  abundant  thin,  sHghtly  offensive,  deeply  bile-stained  fluid 
being  brought  up  at  brief  intervals.  In  cases  of  this  kind  it  was  found  that  the 
cause  was  an  acute  intestinal  obstruction  high  in  the  intestine.  This  obstruction 
may  be  at  the  afferent  opening,  the  proximal  limb  of  the  jejunal  loop  being  water- 
logged, and  causing  a  kink  at  the  anastomosis  where  the  jejunum  is  weakened  con- 
siderably by  the  complete  division  of  its  circular  muscular  fibers,  or  at  the  efferent 
opening,  where  again  a  sharp  kink  or  a  band  of  adhesions  is  found.  Since  the  intro- 
duction by  Petersen  and  Czerny  of  the  "no-loop"  or  "short-loop"  principle  in  pos- 
terior gastro-enterostomy,  regurgitant  vomiting  of  this  type  has  disappeared.  I 
have  not  seen  it  in  over  three  hundred  consecutive  operations. 

(h)  The  intermittent  form  is  observed  in  cases  that  have  done  well  after  opera- 
tion and  have  given  no  anxiety  whatever.  At  a  time  which  varies  from  three  to  four 
weeks  up  to  six  months  the  patients  begin  to  vomit,  and  they  vomit  pure  bile  pain- 
lessly. Even  after  a  meal  it  is  only  bile  which  is  vomited,  not  food.  This  type  of 
vomiting  is  more  common  in  the  morning;  though  it  may  come  on  at  any  time  during 
the  day,  suddenly.  It  is  preceded  occasionally  by  a  "swimming"  in  the  head,  and 
faintness.  W.  J.  Mayo^  has  suggested  that  this  bilious  vomiting  is  due  to  kinking 
of  the  jejunum  either  at  the  duodenojejunal  flexure,  or  at  the  anastomosis,  when 
the  bowel  is  applied  to  the  stomach  along  a  line  whose  direction  is  from  above  down- 
ward and  to  the  right.  He  therefore  suggested  that  the  anastomosis  be  made  with 
the  bowel  passing  from  above  downward  and  to  the  left.  He  further  pointed  out 
that  this  was  the  natural  direction  of  the  jejunum.  In  deference  to  so  great  an 
authority  I  followed  this  method  in  a  series  of  cases,  and  in  two  of  these  bilious 
vomiting  followed.  In  all  my  previous  experience  I  had  only  seen  two  such  cases, 
and  the  proportion  occurring  after  Mayo's  line  of  anastomosis  had  been  followed 
was  therefore  unduly  great.  This  led  me  to  make  a  series  of  observations  upon  the 
jejunal  direction.  In  approximately  60  per  cent,  of  cases  the  jejunum  passes  down- 
ward and  to  the  left  from  the  flexure.  But  in  the  remaining  40  per  cent,  it  may 
occupy  any  direction,  and  my  present  plan  is  therefore  in  performing  the  anasto- 
mosis to  discover  the  normal  jejunal  direction  and  to  preserve  that  direction  in 
making  the  anastomosis.  In  this  way  alone  can  displacements  leading  to  the 
occurrence  of  this  complication  be  avoided. 

Intestinal  Obstruction. — As  I  have  already  mentioned,  regurgitant  vomiting 
is  in  reality  due  to  high  intestinal  obstruction,  and  may  therefore  be  included  under 
this  heading.  Other  forms  of  obstruction  are  met  with,  such  as:  (a)  Bands  or 
adhesions  occurring  between  the  distal  limb  of  the  jejunum  and  the  omentum,  ab- 
dominal wall,  transverse  mesocolon,  etc.  (b)  Hernia  of  the  small  intestine  through 
the  opening  in  the  transverse  mesocolon  into  the  lesser  sac.     (c)  Strangulation  of 

'  Mayo,  Wm.  J.:   "The  Technique  of  Gastro-jejunostomy."  Ann.  of  Surg.,  1906,  xliii,  537. 


342  OPERATIONS  UPON  THE  STOMACH. 

the  small  intestine  over  the  proximal  jejunal  loop,  from  right  to  left  or  left  to  right. 
Cases  of  this  kind  are  considered  by  me  in  detail  elsewhere.^  These  complications 
may  be  avoided  by  extreme  cleanliness  during  the  operation,  so  that  post-operative 
local  peritonitis  (septic?)  is  not  aroused;  by  closure  of  the  mesocolic  opening 
around  the  anastomosis;  by  the  avoidance  of  a  jejunal  loop  between  the  flexure 
and  the  anastomosis. 

Peptic  Ulcer  of  the  Jejunum. — The  occurrence  of  peptic  ulcer  in  the  jejunum 
after  gastro-enterostomy  has  only  attracted  general  attention  since  the  operation 
became  applied  to  the  treatment  of  simple  ulcers.  It  does  not  occur  in  cases  of 
malignant  disease.  The  ulcer  is  generally  found  in  the  distal  limb  of  the  jejunum, 
almost  immediately  below  the  anastomosis;  it  may  be  solitary  or  as  many  as  four 
may  be  found.  Pathologically  and  etiologically  the  ulcer  is  the  counterpart  of 
duodenal  ulcer.  TiegeF  and  Gosset^  have  written  excellent  papers  dealing  with 
this  subject.  Including  the  cases  collected  by  these  two  authors,  two  recorded  by 
Battle,  and  one  case  of  my  own,  there  are  thirty-four  cases  altogether.  The  opera- 
tion performed  in  these  was:  In  seventeen  cases  anterior  gastro-enterostomy;  in 
four  cases  anterior  gastro-enterostomy  with  entero-anastomosis;  in  one  case  gastro- 
enterostomy in  Y;  in  six  cases  posterior  gastro-enterostomy  with  long  loop;  in  one 
case  posterior  gastro-enterostomy  with  entero-anastomosis;  in  one  case  posterior 
gastro-enterostomy  with  short  loop.  In  the  remainder  the  nature  of  the  opera- 
tion is  not  mentioned. 

The  time  which  elapsed  between  the  performance  of  the  gastro-enterostomy 
and  the  discovery  of  the  peptic  ulcer  has  varied  from  ten  days  to  nine  years. 

The  clinical  forms  in  which  the  symptoms  may  appear  are  three : 

1.  The  symptoms  are  the  same  as  those  of  duodenal  ulcer;  pain  some  time  after 
food,  burning  flatulent  distention,  hyperacidity. 

2.  Acute  perforation  occurs  without  inaugural  symptoms. 

3.  The  symptoms  recur,  and  a  "subacute"  perforation  occurs;  there  is  an 
abundant  localized  plastic  peritonitis,  and  a  lump  may  be  felt  in  the  epigastrium. 

The  latter  forms  are  described  by  Tiegel,  but  I  have  seen  one  case,  as  yet  unre- 
corded, of  the  first  type.  It  is  not  improbable  that  in  some  of  the  cases  where  opera- 
tion is  supposed  not  to  have  relieved  the  original  condition  of  duodenal  or  pyloric 
ulcer,  the  symptoms  may  in  reality  be  due  to  secondary  peptic  ulceration  in  the 
jejunum. 

So  far  as  the  cause  is  concerned,  hyperacidity  would  seem  to  be  the  most  fre- 
quent. It  was  noticed  in  eighteen  of  the  thirty-three  cases;  in  the  majority  of  the 
fifteen  remaining  cases  no  observations  upon  this  point  were  made.  Gosset  asserts 
that  three  factors  are  at  work — hyperacidity,  tight  stenosis  of  the  pylorus,  and  great 
dilatation  of  the  stomach.     These,  I  think,  are  only  the  conditions  usually  present 

1  Moynihan,  B.  G.  A.:  "Abdominal  Operations,"  1906,  pp.  205-211,  second  edition,  W.  B. 
Saunders  Co.,  Phila.  and  London. 

^Tiegel,  Max:  "Ueber  peptische  Geschwiire  des  Jejunums  nach  Gastro-enterostomie," 
Mitth.  a.  d.  Grenzgebiet,  1904,  xiii,  No.  31,  p.  897. 

'  Gosset,  A.:   "L'ulcere  peptique  du  jejunum,"  Rev.  de  Chir.,  1906,  xxxiii,  54. 


COMPLICATIONS    FOLLOWING    GASTRO-EXTEROSTOMY.  343 

when  gastro-enterostomy  is  performed.  They  are  factors  necessitating  operations 
in  the  first  instance,  but  can  hardly  be  supposed  to  have  any  causative  influence 
in  producing  a  peptic  ulcer.  A  fourth  cause,  which  was  mentioned  by  Garre 
at  the  discussion  at  the  first  meeting  of  the  International  Surgical  Society,  was 
the  want  of  accurate  apposition  of  the  mucous  edges  at  the  time  of  operation. 
A  raw  surface  is  left  which  allows  of  easy  digestion  by  the  hyperacid  gastric  juice. 
This  probably  accounts  for  some  cases,  but  in  the  majority  of  cases  the  ulcer  is  not 
exactly  at  the  opening,  but  an  inch  or  more  away. 

In*^  the  series  there  were  three  cases  in  which  a  fistula  had  formed  between  the 
jejunum  and  the  colon. 

In  several  of  the  cases  it  was  noticed  that  a  local  swelling  (generally  to  the  left  side 
of  the  epigastrium)  was  present.  In  some  of  these  active  peristalsis  of  a  much  dis- 
tended coil  of  bowel  was  seen.  This  occurred  when  an  anterior  gastro-enterostomy 
had  been  performed;  it  was  due  to  the  distention  of  the  coil  of  jejunum  between  the 
flexure  and  the  anastomosis.  Owing  to  the  plastic  peritonitis  around  the  perfora- 
tion, an  acute  intestinal  obstruction  had  been  caused  at  this  high  point  in  the 

bowel. 

The  occurrence  of  peptic  ulcer  is  certainly  the  most  serious  of  all  disasters  after 
gastro-enterostomy.  It  is  therefore  necessary  in  all  cases  of  duodenal  ulcer  to 
insure  that  adequate  care  in  the  after-treatment  is  observed.  If  hyperchlorhydria 
has  been  marked  or  persistent,  there  should  be  a  continued  administration  of  alkaHs,. 
and  great  care  in  diet  for  weeks,  or,  if  need  be,  months.  If  operation  is  called  for, 
a  jejunal  resection  is  probably  the  best  treatment  and  the  subsequent  making  of 
a  new  anastomosis. 

Diarrhea.— This  is  an  occasional  sequel  to  the  operation  deserving  of  mention 
because  of  the  fact  that  it  has  in  rare  cases  proved  fatal.  Our  knowledge  of  the 
subject  has  been  advanced  by  Anschutz'  and  KeUing." 

KelHng  remarks  that  in  the  cases  which  prove  fatal  no  obvious  explanation  of 
the  diarrhea  is  discoverable.  He  suggests  that  there  are  two  forms:  First,  that 
in  which  the  diarrhea  is  due  to  the  escape  into  the  intestine  of  acid  contents  not 
neutrahzed  by  the  bile  and  the  pancreatic  juice;  second,  that  in  wliich  it  is  due  to 
"fermentation."  The  latter  is  not  serious,  and  is  seen  only  or  chiefly  in  patients 
suffering  from  carcinoma,  or  in  those  cases  where  there  is  an  absence  of  free  HCl. 

The  explanation  of  the  first  form  lacks  adequate  confirmation.  In  spite  of  the 
fact  that  both  bile  and  pancreatic  juice  may  almost  constantly  be  found  in  the  stom- 
ach after  gastro-enterostomy,  acid  contents  may  still  escape  into  the  intestine,  and 
may,  indeed,  cause  peptic  ulcer.  But  it  has  not  yet  been  suggested  or  recognized 
that  diarrhea  occurs  especially  in  those  suffering  from  hyperchlorhydria,  as  one 
would  expect  if  this  hypothesis  were  accurate. 

With  regard  to  the  explanation  of  the  second  form,  this  may  be  true  in  certam 

1  Anschiitz,  Willy:  "Ueber  die  Darmstorungen  nach  Tragenoperationen,"  Mitth.  a.  d.  Grenz- 
gebiet,  1905,  XV,  305.  ,   ..   „., 

^  Kelling,  George:  "Studien  zur  Chirurgie  des  Magens,"  Archiv.  f.  klin.  Chir.,  1900,  Ix.i,  3-. 


344  OPERATIONS  UPON  THE  STOMACH. 

cases.  Fermentation  may  go  on  to  such  a  degree  in  the  stomach  that  no  amount 
of  careful  lavage  will  insure  the  cleanliness  of  the  mucosa.  This  may  be  proved 
by  examining  a  pyloric  growth  after  pylorectomy  has  been  performed;  the  recesses 
of  the  regular  mass  are  sometimes  extremely  foul.  The  delivery  of  putrid,  fer- 
menting food  into  the  jejunum  would,  of  course,  instantly  set  up  diarrhea.  It  is 
always  remarked  that  the  stools  in  such  a  case  are  "very  offensive."  But  in  not  a 
few  cases  the  diarrhea  does  not  appear  at  once,  but  only  after  several  days,  when 
the  patient  has  perhaps  been  doing  well.  It  should  be  remarked  that  cases  have 
occurred  after  partial  gastrectomy,  when  the  infective  area  has  been  removed. 

Anschiitz  believes  the  chief  cause  to  be  the  excessive  weakness  of  the  patient, 
and  remarks  that  the  same  type  of  diarrhea  is  seen  in  those  who  suffer  from  advanced 
carcinoma  elsewhere,  or  from  extensive  tuberculous  disease  apart  from  intestinal 
lesions.  Carle  and  Fantino  remark  that  the  food  runs  through  the  intestine  Hke 
water  through  a  rubber  tube,  which  is  powerless  to  hasten  or  impede  its  progress. 

It  is  apparent  that  no  adequate  explanation  of  this  complication  can  be  given, 
but  it  is  probable  that  a  strict  attention  to  the  diet,  the  administration  of  only  sterile 
foods  for  some  time  after  the  operation,  the  giving  of  opium  early,  and  the  exhibi- 
tion of  drugs,  such  as  isoform,  naphthol,  salol,  etc.,  whose  purpose  is  to  act  as  disin- 
fectants, will  comprise  the  most  effective  means  at  our  disposal  for  preventing  and 
for  checking  the  onset  of  this  symptom. 


EXCISION  OF  ULCERS. 

There  are  certain  cases  of  chronic  ulcer  of  the  stomach  which  are  not  suitable 
for  gastro-enterostomy.  When  the  ulcer  is  situated  on  the  lesser  curvature  in  its 
cardiac  half,  the  performance  of  a  short-circuiting  operation  will  not  afford  relief, 
or  will  relieve  only  for  a  time,  the  symptoms  recurring  with  as  great  severity  as  ever 
within  a  few  months  of  the  operation.  In  two  such  cases  I  performed  gastro- 
enterostomy, three,  and  three  and  a  half  years  ago;  in  both  cases  there  was  great 
improvement  for  a  time,  but  in  both  a  relapse  has  occurred.  If  an  ulcer  on  the 
lesser  curvature  is  solitary,  it  should  be  excised;  if  there  are  more  ulcers  than  one, 
an  ulcer  near  the  cardia  and  an  ulcer  at  the  pylorus  causing  stenosis,  the  former 
should  be  excised  and  gastro-enterostomy  then  performed;  or  if  the  patient's  con- 
dition be  very  serious,  gastro-enterostomy  alone  may  be  done  at  the  first,  and  the 
excision  of  the  ulcer  deferred  till  a  more  suitable  occasion. 

The  excision  of  the  ulcer  is  carried  out  in  the  following  manner :  The  abdomen 
is  opened  and  the  stomach  inspected,  and  surrounded  at  the  sides  and  below  with 
swabs.  The  gastrohepatic  omentum  is  then  cut  through  about  one  inch  away 
from  the  stomach,  above  the  ulcer,  and  the  incision  carried  down  to  ih.e  lesser  cur- 
vature. On  the  curvature  the  coronary  artery  is  divided  at  each  side  of  the  ulcer; 
two  ligatures  are  tied  at  each  point  and  the  artery  is  severed  between  them.  The 
finger  is  then  passed  into  the  lesser  sac  to  discover  the  presence  of  adhesions  between 
the  ulcer  and  the  pancreas.     These,  if  found,  are  separated,  and,  the  stomach 


THE    OPERATIVE   TREATMENT    OF   HOUR-GLASS    STOMACH.  345 

being  free,  the  clamps  are  applied.  The  area  of  the  stomach  embraced  by  them 
should  be  triangular,  the  base  being  at  the  lesser  curvature,  the  apex  pointino- 
toward  the  greater  curvature.  The  wedge-shaped  portion  of  the  stomach  between 
them  is  to  be  removed,  but  it  is  important  that  the  depth  of  the  wedge  should  be  no 
greater  than  is  absolutely  necessary;  for  if  much  of  the  stomach,  in  depth,  is  re- 
moved, an  unsightly  and  possibly  troublesome  kink  may  result.  The  clamps  being 
applied,  the  stomach  area  between  them  is  removed.  The  closure  of  the  wound  left 
is  begun  by  suturing  the  posterior  margins  at  the  point  nearest  the  greater  curvature. 
The  needle  is  passed  from  the  mucosa  of  one  side  to  the  mucosa  of  the  other,  and 
then  returns  from  mucosa  to  mucosa,  where  a  knot  is  tied.  The  suture  begun  in 
this  way  is  continued  with  the  "loop  on  the  mucosa"  stitch  already  described;  it  is 
continued  upward  along  the  posterior  surface  to  the  lesser  curvature,  then  down  on 
the  anterior  surface.  This  stitch  is  then  tied  and  cut  short.  The  whole  suture 
line  should  be  secure,  and  when  the  clamps  are  removed  should  be  water-tight. 
A  second  outer  suture  is  now  introduced,  which  picks  up  the  serosa  and  muscularis, 
and  infolds  and  reinforces  the  :Grst  line.  The  inner  suture  may  be  of  catgut;  the 
outer  should  be  of  celluloid  thread  or  silk. 

It  is  important  in  this  operation  to  have  as  much  as  possible  of  the  healthy 
stomach  wall  between  the  ulcer  which  is  to  be  removed  and  the  greater  curvature, 
so  that  there  shall  be  no  present  kinking,  and  no  risk  of  subsequent  contraction 
resulting  in  stenosis. 


THE  OPERATIVE  TREATMENT  OF  HOUR-GLASS  STOMACH. 

Definition. — By  the  term  hour-glass  stomach  is  understood  that  condition  in 
which,  as  the  result  of  a  narrowing  in  the  body  of  the  stomach  at  any  point  between 
the  cardiac  and  pyloric  orifices,  the  organ  is  divided  into  two  cavities. 

Hour-glass  stomach  (Sanduhrmagen,  Vestomac  biloculaire)  is  always  the  result 
of  a  pathologic  change  occurring  in  the  body  of  the  stomach;  it  is  never  congenital 
in  origin.  The  constriction  which  divides  the  stomach  into  two  pouches  may  be 
due  to  chronic  ulceration,  to  cancer,  or  to  adhesions  pressing  upon  the  stomach 
(rarely).  A  chronic  ulcer,  more  especially  the  saddle-shaped  ulcer  which  extends 
along  the  lesser  curvature  and  down  both  surfaces,  in  healing  puckers  the  stomach 
in  or  near  its  center;  as  a  rule,  the  greater  curvature  is  drawn  up  to  the  lesser,  but 
I  have  twice  seen  the  lesser  pulled  down  to  the  greater  curvature.  In  the  majority 
of  cases  of  hour-glass  stomach  the  scar  of  other  ulcers  is  seen  at  or  near  the  pylorus, 
or  in  the  duodenum — testimony  of  some  value  in  support  of  the  fact  that  ulcer  of 
the  stomach  is  not  usually  solitary.  The  result  of  this  double  constriction  is  that 
the  food  has  difficulty  in  escaping  from  the  cardiac  pouch  to  the  pyloric  pouch,  and 
from  the  latter  into  the  duodenum ;  both  pouches  then  undergo  dilatation  and  per- 
haps hypertrophy.  The  pyloric  pouch  in  such  circumstances  has  been  mistaken  for 
the  whole  stomach  and  a  futile  operation  of  anastomosis  performed  between  it 
and  the  intestine. 


346  OPERATIONS  UPON  THE  STOMACH. 

Symptoms. — An  hour-glass  stomach  can  usually  be  recognized  by  attention 
to  the  following  symptoms  and  signs : 

1.  If  the  stomach-tube  be  passed,  and  the  stomach  washed  out  w^ith  a  known 
quantity  of  fluid,  the  loss  of  a  certain  quantity  will  be  observed  when  the  return 
fluid  is  measured.  Thus,  if  30  ounces  be  used,  only  24  can  be  made  to  return. 
Wolfler,  who  called  attention  to  this  sign,  said  that  some  of  the  fluid  seemed  to  dis- 
appear "as  though  it  had  flowed  through  a  large  hole  " — as  indeed  it  has,  in  passing 
from  the  cardiac  to  the  pyloric  pouch  (Wolfler's  "first  sign"). 

2.  If  the  stomach  be  washed  out  until  the  fluid  returns  clear,  a  sudden  rush  of 
foul,  evil-smelling  fluid  may  occur;  or,  if  the  stomach  be  washed  clean,  the  tube 
withdrawn  and  passed  again,  in  a  few  minutes  several  ounces  of  dirty  offensive  fluid 
may  escape.  The  fluid  has  regurgitated  through  the  connecting  channel  between 
the  pyloric  and  cardiac  pouches  (Wolfler's  "second  sign"). 

3.  "Paradoxic  dilatation. "  If  the  stomach  be  palpated  and  a  succussion  splash 
obtained,  the  stomach-tube  passed,  and  the  stomach  apparently  emptied,  palpation 
will  still  ehcit  a  distinct  splashing  sound.  This  is  due  to  the  fact  that  only  the 
cardiac  pouch  is  drained ;  the  contents  of  the  pyloric  remain  undisturbed  and  cause 
the  splashing  sound  on  palpation.  For  this  phenomenon  Jaworski  has  suggested 
the  appropriate  name  "paradoxic  dilatation."  Jaboulay  has  pointed  out  that  if 
the  cardiac  loculus  be  filled  with  water,  a  splashing  sound  can  still  be  obtained  by 
palpation  over  the  pyloric  pouch.  The  sign  of  paradoxic  dilatation  is  best  ehcited 
after  w^ashing  out  the  stomach  in  the  ordinary  manner.  When  the  abdomen  is 
examined  at  the  completion  of  the  washing,  and  when  the  stomach  has  been  appa- 
rently drained  quite  dry,  a  splashing  sound  is  readily  obtained,  for  some  of  the  fluid 
used  has  escaped  into  the  pyloric  pouch  through  the  connecting  channel. 

4.  Von  Eiselsberg  observed  in  one  of  his  cases  that  on  distending  the  stomach  a 
bulging  of  the  left  side  of  the  epigastrium  was  produced;  after  a  few  moments  this 
gradually  subsided,  and  concomitantly  there  was  a  gradual  filling  up  and  bulging 
of  the  right  side. 

5."  Von  Eiselsberg  also  called  attention  to  the  bubbhng,  forcing,  "sizzhng"  sound 
which  can  be  heard  when  the  stethoscope  is  applied  over  the  stomach  after  disten- 
tion with  CO  2-  If  the  two  halves  of  a  SeidHtz  powder  are  separately  given  and  the 
stomach  be  normal  or  dilated,  no  loud  sound  is  heard  anywhere  except  at  the 
pylorus;  if  a  constriction  is  present  in  the  stomach,  a  loud,  forcible,  gushing  sound 
can  be  easily  distinguished  at  a  point  two  or  three  inches  to  the  left  of  the  middle 
line. 

6.  I  first  called  attention  six  years  ago  to  a  sign  which  I  have  since  found  of  great 
service  in  establishing  a  diagnosis  of  hour-glass  stomach.  The  abdomen  is  carefully 
examined  and  the  stomach  resonance  percussed.  A  Seidlitz  powder  in  two  halves 
is  then  administered.  On  percussing,  after  about  twenty  or  thirty  seconds  an  enor- 
mous increase  in  the  resonance  of  the  upper  part  of  the  stomach  can  be  found,  while 
the  lower  part  remains  unaltered.  If  the  pyloric  pouch  can  be  felt,  or  seen  to  be 
clearly  demarcated,  the  diagnosis  is  inevitable,  for  the  increase  in  resonance  must 


THE    OPERATIVE   TREATMENT    OF   HOUR-GLASS    STOMACH. 


347 


Fig.  577. — Operation   for   Hour-glass  Stomach. 


be  in  a  distended  cardiac  segment.  If  the  abdomen  be  watched  for  a  few  minutes, 
the  pyloric  pouch  may  sometimes  be  seen  gradually  to  fill  and  become  prominent. 
7.  Schmidt-Monard  and  Eichhorst  have  seen  a  distinct  sulcus  between  the  two 
pouches  inflated  with  COj.  In  one  of  my  cases  the  pouches  could  be  emptied,  one 
into  the  other,  through  the  constriction. 

Operative  Treatment. — The  opera- 
tive treatment  of  hour-glass  stomach  at 
times  offers  very  serious  difficulties.  In 
the  first  place,  there  may  be  two  constric- 
tions— one  in  the  body  of  the  stomach  and 
one  at  the  pylorus.  If  so,  a  double  opera- 
tion may  be  necessary,  for  gastro-enteros^ 
tomy  from  the  cardiac  pouch  leaves  the 
pyloric  pouch  undrained,  and  an  anasto- 
mosis from  the  pyloric  pouch,  being  beyond 
the  first  and  most  important  obstruction, 
can  give  no  relief.  Again,  the  cardiac 
pouch  in  some  cases  is  small;  in  one  in- 
stance  I  have  seen  it  no   larger  than  an 

orange.  In  such  circumstances  it  is  inaccessible,  or  almost  so;  and  if  adhesions 
conceal  it,  the  mechanical  difficulties  of  any  operation  are  excessive.  The  supreme 
fact  to  be  borne  in  mind  is  that  before  any  operation  is  undertaken  the  whole  stom- 
ach, from  cardia  to  pylorus,  must  be  examined.  In  one  of  my  own  cases  a  trifid 
stomach  was  discovered;  but  for  this  rule  it  would  certainly  have  been  overlooked. 

The  various  operations  that  may  be 
practised  are:  (1)  Gastro  -  enterostomy 
from  the  cardiac  pouch.  (2)  Gastro- 
enterostomy from  both  pouches.  Weir  and 
Foote's  operation.  (3)  Gastro-enterostomy 
in  Y  into  both  pouches,  ^Nlonprofit's  opera- 
tion. (4)  Gastroplasty.  (5)  Gastro-gas- 
trostomy.  (6)  Partial  gastrectomy.  (7) 
Digital  divulsion  of  the  constriction. 

1.  Gastro-enterostomy  from  the  cardiac 
pouch  is  the  operation   often  most  prac- 
ticable;   for  the   cardiac   pouch  is  almost 
always  the  larger  and  the  pyloric  pouch 
may  be  small  and  negligible.     The  opera- 
tion   is    performed    between    the    cardiac 
pouch  and  the  jejunum,  exactly  as  if  the  pouch  were  the  whole  stomach  (Fig.  577). 
2.  Weir  and  Foote  suggested  that  the  loop  of  jejunum  selected  for  the  anasto- 
mosis with  the  stomach  should  be  united  to  both  pouches,  first  to  the  cardiac,  then 
the  pyloric,  both  of  which  would,  therefore,  be  drained  (Fig.  578). 


Fig.  578 


-Operation  for  Hour-glass  Stomach 
(Weir  and  Foote). 


348 


OPERATIONS  UPON  THE  STOMACH. 


3.  Monprofit  performed  an  anastomosis  between  the  two  pouches  and  the  jejunum 

after  the  method  of  Roux,  the  gastro-enter- 
ostomy  in  Y.  The  necessity  for  a  double 
division  of  the  jejunum  and  of  four  anas- 
tomoses is  an  insuperable  objection  to  this 
operation. 

4.  Gastroplasty.  In  my  early  cases  I 
performed  gastroplasty  with  the  same 
hopefulness  as  pyloroplasty;  but  in  both 
operations  I  have  been  disappointed. 
Gastroplasty  is  the  operation  of  pyloro- 
plasty applied  to  the  body  of  the  stomach 
(Fig.  579).  It  is  only  applicable,  there- 
fore, in  those  cases  in  which  there  is  no 
active  ulceration,  when  the  scar  tissue  is  of 
limited  extent,  and  where  the  induration  is 
not  extensive.  If  it  is  ever  to  meet  with 
success  it  must  be  performed  in  the  man- 
ner suggested  by  Kammerer,^  of  New 
York,  which  is  an  application  to  gastro- 
plasty of  a  method  which  bears  to  it  the 
same  relationship  as  does  Finney's  opera- 
tion to  pyloroplasty.  The  following  is 
Kammerer's  description : 

"Beginning  at  the  lowest  point  of  the 
constriction,  a  running  suture  was  applied 
through  the  serous  and  muscular  coats,  bringing  the  vertical  edges  of  both  compart- 
ments of  the  stomach  into  close  approxima- 
tion along  their  posterior  margins.  An  in- 
verted V-shaped  incision  was  now  made 
through  the  entire  thickness  of  the  stom- 
ach-wall, about  I  inch  to  either  side  of  the 
Lembert  suture  (Fig.  580).  The  posterior 
wound  edges  were  now  brought  together 
with  another  running  suture  from  within, 
the  same  procedure  being  then  applied  to 
the  anterior  edges  from  without.  The  final 
act  of  the  operation  consisted  in  reinforcing 
the  anterior  suture  with  a  running  Lembert 
stitch,  and  placing  a  few  extra  sutures  at 
the  lowest  point  of   the   stomach    through 

the   serous  and    muscular  coats,  where   tension   would   naturally  be   greatest. 
*  Kammerer.  F.:    "Hour-glass  Contraction  of  the  Stomach,"  Ann.  of  Surg.,  1903,  i,  281. 


Fig.  579. — Gastroplasty  for  Hour-glass 
Stomach. 


Fig.  580. — Kammerer's  Gastroplasty  for 
Hour-glass  Stomach. 


GASTRECTOMY. 


349 


5.  Gastro-gastrostomy  or  gastro-anastomosis  is  suited  to  those  cases  only  in 
which  there  is  no  obstruction  at  the  pylorus.  The  two  pouches  are  united  to  one 
another  by  an  anastomotic  opening  which  reaches  from  the  lesser  curvature  to  the 
greater  (Fig.  581).  When  the  stomach  is  well  drawn  into  the  wound,  a  clamp  is 
placed  on  each  pouch  close  to  the  isthmus, 

and  is  made  to  embrace  the  whole  depth 
of  the  stomach,  from  one  curvature  to  the 
other.  The  clamps  are  then  isolated  by 
gauze,  and  the  parts  embraced  by  them 
united  by  suture,  in  exactly  the  same 
manner  as  in  gastro-enterostomy. 

6.  Partial  gastrectomy  is  applicable  to 
the  cases  in  which  the  stenosis  in  the 
stomach  is  due  to  carcinoma,  the  whole  of 
the  isthmus,  the  gastro-hepatic  omentum, 
and  the  adjacent  glands  on  both  curvatures 
are  removed,  and  an  end-to-end  anasto- 
mosis made  between  the  two  cut  surfaces. 

7.  Digital  divulsion  may  be  described 
as  the  application  of  Loreta's  operation  to 
the  constriction  in  the  stomach.  It  is 
never  likely  to  have  any  but  the  most  re- 
stricted role.  In  one  case,  however,  it  yielded  me,  when  all  other  measures  were 
impossible,  a  most  remarkable  result. 


Fig.  581. 


Gastrogastrostomy  for   Hour-glass 
Stomach. 


GASTRECTOMY. 

Definition. — Gastrectomy  is  the  operation  in  which  a  removal  of  the  whole  or 
a  part  of  the  stomach  is  undertaken.  It  is  described  as  "complete  gastrectomy" 
in  the  former  case,  as  "partial  gastrectomy"  in  the  latter.  The  term  "pylorec- 
tomy  "  was  formerly  used  to  indicate  the  removal  of  a  growth  having  its  origin  in  the 
pylorus,  but  the  term  has  now,  very  properly,  fallen  into  disuse. 

History.^ — The  first  experimental  work  dealing  with  the  question  of  resection  of 
the  stomach  was  undertaken  in  1810  by  Merrem,  who  removed  the  pylorus  with 
success  in  one  case.  In  1876  Gussenbauer  and  Winiwarter,  and  later  Czerny  of 
Heidelberg,  performed  a  series  of  successful  operations  upon  dogs,  and  suggested 
the  possibiUty  of  similar  operations  in  the  human  subject.  On  April  9,  1879,  Pean 
performed  the  first  "pylorectomy"  in  man,  and  in  1880  Rydygier  the  second;  both 
operations  were  unsuccessful.  On  February  28,  1881,  Bihroth  performed  the  first 
operation  which  was  followed  by  recovery;  a  malignant  tumor  of  the  pylorus  was 
removed.     Since  this  time  a  large  amount  of  work,  pathologic,  anatomic,  and  oper- 

'■  For  a  history  of  this  operation  with  references  see  Rydygier,  Luchvig:  "Meine  Erfahr- 
ungen  iiber  die  von  niir  seit  1880  bis  jetzt  ausgefiihrter  Magenoperationen,"  Deut.  Zeit.  f.  Chir., 
1901,lviii,  197. 


350 


OPERATIONS    UPON   THE    STOMACH. 


ative,  has  been  undertaken,  with  the  gratifying  result  that  the  removal  of  carcinoma 
of  the  stomach  can  now  be  undertaken  with  a  success  that  only  ten  years  ago  seemed 
unattainable.  The  work  upon  the  lymphatics  of  the  stomach  by  Cuneo,  upon  the 
pathologic  anatomy  of  carcinoma  of  the  stomach  by  Mikulicz,  Borrmann,  and 
Cuneo,  and  upon  the  operative  technic  by  Mikuhcz,  Hartmann,  Rutherford  Mori- 
son,  Moynihan,  and  W.  J.  IMayo,  is  all  noteworthy. 


Fig.  582. — Partial  Gastrectomy  for  Hour-glass  Stomach. 


Complete  gastrectomy  was  first  performed  in  1883  by  Connor,  of  Cincinnati, 
in  1884,  by  Schuchardt,  and  in  1892  by  Maydl;  all  the  patients  died.  The  first 
successful  complete  gastrectomy  was  performed  by  Schlatter,  of  Zurich,  on  Septem- 
ber 6,  1897;  the  second  case  by  C.  B.  Bringham,  of  Boston,  on  February  24,  1898. 
In  the  former  of  these  the  cut  end  of  the  esophagus  was  united  to  a  loop  of  the 
jejunum  by  suture,  the  duodenal  end  being  closed;  in  the  latter  the  cut  ends  of  the 
esophagus  and  duodenum  were  united  over  a  INIurphy  button. 


GASTRECTOMY. 


351 


Conditions  for  Which  the  Operation  is  Performed. — Complete  gastrectomy 
has  only  been  undertaken  in  cases  of  carcinoma  of  a  large  part  of  the  stomach.  Its 
role  will  always  be  very  limited,  and  no  cases  but  those  of  malignant  disease  are 
ever  likely  to  be  submitted  to  so  serious  an  operation. 

Partial  gastrectomy  in  the  great  majority  of  cases  is  performed  for  carcinoma 
of  the  stomach,  beginning  in  or  near  the  pylorus,  or  more  rarely  in  the  body  of  the 
stomach.     In  certain  cases  the  removal 

of  a  large  part  of  the  organ  may  be  »serous  suture 

thought  necessary  in  cases  of  simple 
ulcer,  and  W.  L.  Rodman  has  sug- 
gested as  the  ideal  operation  for  ulcer 
occupying  the  pylorus  or  pyloric  an- 
trum, in  which  ulcers  are  not  seldom 
multiple,  the  "excision  of  the  ulcer- 
bearing  area"  (Rodman's  operation). 
In  cases  of  ulcer  with  excessive  indur- 
ation a  large  tumor  may  be  formed, 
and  the  mimicry  of  malignant  disease 
by  such  a  mass  is  complete;  Czerny, 
Kocher,  and  others  have  removed  such 
tumors  in  the  belief  that  they  were 
dealing  with  carcinoma.  In  cases  of 
chronic  ulcer  of  the  stomach  the  re- 
moval of  the  ulcer  may,  at  times,  be 
necessary;  for  example,  when  the  ulcer 
occupies  the  lesser  curvature  and  is 
adherent  to  the  under  surface  of  the 
liver  or  the  diaphragm.  In  such  cases 
gastro-enterostomy  alone  does  not  af- 
ford complete  relief,  and  a  "partial 
gastrectomy"  is  therefore  desirable. 
In  some  cases  of  hour-glass  stomach 
an  indurated  ulcer  at  the  isthmus  may 
be  removed,  and  the  two  pouches 
anastomosed. 

Carcinoma  of  the  Stomach. — 
Cancer  of  the  stomach  may  affect  the 
orifices  or  any  part  of  the  body  of  the 

organ.  In  the  great  majority  of  cases  it  commences  within  3  inches  of  the  pylorus. 
An  investigation  of  cases  under  my  own  care^  showed  that  two  forms  of  diseases 
maybe  present — "pyloric"  and  "pre-pyloric."     In  the  pyloric  growths  the  dis- 

iMoynihan,  B.  G.  A.:  "A  Review  of  a  Series  of  Operations  for  Cancer  of  the  Stomach," 
Brit.  Med.  Jour.,  1906,  i,  370. 


Fig.    583  — Partial 


Gastrectomy 

Stomach. 


FOR      HorR-GLASS 


352 


OPERATIONS    UPON   THE   STOMACH. 


ease  begins  in  the  pylorus  or  within  a  very  short  distance  of  it,  and  at  the  earHest 
stage  begins  to  cause  constriction  there.  The  tumor,  as  a  rule,  is  comparatively 
small,  is  largest  at  the  pylorus,  and  gradually  tails  off  along  the  curvatures, 
chiefly  the  lesser  curvature.  At  an  early  stage  there  is  enlargement  of  the 
coronary  glands.  The  "  pre-pyloric "  growth  begins  almost  always  at  the  same 
point,  on  the  lesser  curvature,  li  to  2^  inches  from  the  pylorus.  The  growth  spreads 
along  the  curvature  in  both  directions,  but  chiefly  away  from  the  pylorus,  drifting 
along  with  the  lymphatic  stream.  It  is,  therefore,  some  little  time  before  the  pylorus 
itself  is  involved,  or  before  there  is  such  an  increase  in  the  size  of  the  growth  as  to 


Fig.  584. — Partial  Gastrectomy  for  Hour-glass  Stomach. 


determine  obstruction.  The  origin  of  the  growth,  as  indicated  by  the  thickest 
part  of  it,  is  on  the  lesser  curvature;  Jrom  here  the  growth  extends  along  the  curva- 
ture in  both  directions,  and  down  both  anterior  and  posterior  walls.  Two  wings  of 
growth  are,  as  it  were,  hinged  on  to  a  body  which  is  longer  than  either,  thicker  in 
the  middle,  and  tapering  toward  each  end. 

The  symptoms  in  the  two  forms  of  growth — "pyloric"  and  "pre-pyloric" — 
differ  to  a  degree  which  should  make  their  recognition  before  operation  a  matter 
of  little  or  no  difficulty.  In  the  pyloric  form  the  symptoms  from  the  outset  are  of  an 
obstructive  character;  there  are  stasis  of  food,  inability  to  take  solids,  and  vomiting 


GASTRECTOMY.  353 

in  quantities  which  increase  with  the  increasing  capacity  of  the  stomach.  In  these 
cases  the  stomach  is  obviously  dilated,  and  waves  of  peristalsis  are  easily  seen  or 
easily  elicited  by  slight  inflation  of  the  stomach.  A  growth  placed  as  these  are  need 
not  be  of  large  size  to  cause  the  most  marked  symptoms.  It  does  not  require  a 
large  mass  to  block  the  pylorus  effectively. 

In  the  " pre-pyloric "  form  the  symptoms  are  not  obstructive  in  the  earUest  stage; 
it  is  only  when  the  pylorus  is  invaded,  or  the  large  size  of  the  growth  blocks  the  nar- 
row pyloric  antrum,  that  there  is  any  impediment  to  the  onward  passage  of  food. 
Before  this  time  the  symptoms  are  loss  of  appetite,  intolerance  of  solid  food,  uneasi- 
ness after  meals,  occasional  vomiting  of  a  turbid  watery  fluid  in  small  quantities, 
and  loss  of  weight.  These  symptoms  are  all  mentioned  in  the  history  of  my  cases, 
though  any  one  or  more,  or  even  all,  of  them  may  be  absent  in  any  individual  patient. 

The  connection  between  ulcer  of  the  stomach  and  carcinoma  is  becoming  clearer. 
The  pathologic  evidences  of  any  connection  are  at  present  slight.  It  is  compara- 
tively rare  to  see  a  specimen  in  a  museum  or  on  the  post-mortem  table  in  which  the 
evidence  is  clear  that  an  ulcer  has  preceded  the  development  of  cancer;  but  this 
is  hardly  surprising,  for  the  final  ruin  of  the  disease,  which  is  then  open  to  inspection, 
has  no  trace  remaining  of  the  early  stage  of  its  history.  It  is  probably  by  the  ex- 
amination of  specimens  removed  by  operation  that  the  connection  between  ulcer 
and  cancer  will  be  demonstrated.  What  is  quite  certain  is  that  the  majority  of 
the  cases  of  carcinoma  which  now  come  to  the  surgeon  for  treatment  give  a  clear 
history  of  chronic  gastric  ulcer,  such  a  history  as,  with  our  present  experience 
would  have  compelled  the  surgeon  to  have  advised  operation  years  before,  had  his 
opinion  then  been  asked.  It  is  curious  to  find  that  the  statistics  of  W.  J.  Mayo, 
Mayo  Robson,  and  myself  all  show  that  in  almost  exactly  60  per  cent,  of  cases  of 
cancer  it  is  as  certain  as  a  reliable  clinical  history  can  make  it  that  the  disease 
has  sprung  up  in  a  stomach  which  has  previously  been  the  seat  of  a  chronic  ulcer. 
The  diagnosis  of  carcinoma  of  the  stomach  in  an  earlier  stage  than  is  now  customary 
will  be  possible  if  the  following  type-history  be  borne  in  mind. 

The  type-history  of  a  case  of  carcinoma  is  as  follows:  A  man  or  woman  of 
middle  age  has  suffered  for  a  few  or  for  many  years  from  indigestion,  pain  after  food, 
vomiting,  and  inability  to  take  the  ordinary  food  in  ordinary  quantity;  these  symp- 
toms have,  it  may  be,  come  on  in  "attacks,"  in  the  intervals  of  which  there  has  been 
comparative  or  complete  freedom  from  suffering.  At  last  an  "attack"  comes  that 
is  more  rebellious  than  the  others,  vomiting  is  more  persistent,  and  the  loss  of  weight 
is  unusual.  The  remedies  which  before  gave  relief  are  now  without  eflfect.  If  in 
such  a  patient  there  be  gastric  stasis,  food  being  retained  for  ten  or  twelve  hours, 
if  there  be  persistent  absence  of  free  HCl  after  a  test  meal,  if  lactic  acid  be  present, 
and  if  in  the  test  meal  when  removed  blood  is  found  on  microscopic  examination, 
then  there  is  a  very  strong  warrant  for  a  diagnosis  of  carcinoma,  and  an  exploratory 
operation  is  not  only  justified— it  is  demanded.  In  discussing  this  question  of  ex- 
ploration, it  is  well  to  be  clear.  There  can  be  no  question  that  an  exploratory  opera- 
tion is  a  confession  of  diagnostic  failure;  we  do  not  explore  the  abdomen  for  condi- 
voL.  11—23 


354. 


OPERATIONS    UPON   THE   STOMACH. 


Coronary 
curren t 


tions  wliich  we  can  now  diagnose  with  certainty,  conditions,  it  may  be,  which  twenty 
years  ago  we  were  not  capable  of  recognizing  with  precision,  conditions  such  as 
duodenal  ulcer  or  stone  in  the  common  duct.  But  no  one  would  hesitate  to  say  that 
positive  recognition  of  cancer  of  the  stomach  in  its  early  stage — in  the  stage,  that  is, 
when  it  could  be  completely  eradicated — is,  with  present  clinical  methods,  almost 
impossible.  If  so,  it  should  be  frankly  admitted,  and  the  only  certain  method — 
exploratory  operation — be  vindicated.  If  the  clinical  liistory  of  a  case  is  such  that 
suspicions  created  at  the  first  are  not  quickly  allayed,  then  the  abdomen  should  be 
opened  to  enable  a  diagnosis  to  be  made.  Exploration  should  be  used  for  the  pur- 
pose of  inaking,  not  with  the  object  of  confirming,  a  diagnosis.  It  is  probable  that, 
as  in  other  matters,  the  comparison  of  the  history  and  of  the  conditions  revealed 
at  operation  will  lead  by  degrees  to  greater  assurance  in  our  diagnosis.  Before  an 
exploratory  operation  is  sanctioned,  however,  the  clinical  investigation  should  be 

as  complete  as  it  is  possible  to  make  it. 
Pathologic  Anatomy. — The  growth 
having  once  begun  in  the  stomach,  it  is 
necessary,  before  purposeful  operative 
measures  can  be  adopted  for  its  relief, 
that  we  should  possess  accurate  knowl- 
edge of  the  lymphatic  distribution  of 
the  organ;  for  the  successful  operative 
treatment  of  malignant  disease  in  any 
organ  implies  a  full  and  accurate 
knowledge  of  its  lymphatic  supply. 

There   are   in   the    stomach    three 
lymphatic  areas : 

1.  An  area  along  the  lesser  curva- 
ture, occupying  two-thirds  of  the  depth 
of  the  stomach;    its  lymph-vessels  run 
obliquely  upward  and  to  the  left  to  the  coronary  glands  which  lie  along  the  lesser 
curvature  as  far  up  as  the  esophagus. 

2.  An  area  along  the  greater  curvature,  occupying  one-third  of  the  breadth  of 
the  organ;  its  lymph- vessels  run  obliquely  to  the  right,  and  end  in  the  glands  of 
the  greater  curvature  which  lie  along  the  right  gastro-epiploic  artery. 

3.  An  area  occupying  the  greater  tuberosity  of  the  stomach,  which  is  discon- 
nected, so  far  as  its  lymphatic  supply  is  concerned,  from  the  rest  of  the  organ — this 
is  the  "isolated  area."  Its  vessels  run  to  the  left  and  terminate  in  glands  in  the 
hilum  of  the  spleen. 

The  removal  of  the  growth  which  begins  as  a  "pyloric"  or  " pre-pyloric "  cancer 
must,  therefore,  involve  the  removal  of  the  growth  itself,  of  all  the  lymphatic  vessels 
draining  the  area  of  the  growth,  of  the  glands  into  which  those  vessels  empty. 

To  effect  this,  it  is  clear  that  the  whole  of  the  lesser  curvature  up  to  the  esophagus 
must  be  taken  away.     The  point  on  the  greater  curvature  at  which  the  point  of  sec- 


■^'^o^c  current 
Fig.    585 


The   Lymphatic   Areas   of   the    Stomach 
(after  Cuneo). 


PARTIAL    GASTRECTOMY.  355 

tion  is  to  be  made  should  in  theory  be  at  the  margin  of  the  "isolated  area,"  as  I 
described  it  in  my  first  paper/  but  in  practice  such  an  operation  is  technically  very 
difficult.  It  is  to  Cuneo  and  Hartmann  that  we  are  indebted  for  a  very  helpful 
suggestion.  These  surgeons  point  out  that  as  the  lymphatic  current  along  the 
greater  curvature  was  toward  the  pylorus  and  the  growth,  the  involvement  of  these 
vessels  by  the  spread  of  the  carcinoma  was  unlikely,  and  they  accordingly  suggested 
that  a  much  larger  part  of  the  greater  curvature  might  safely  be  left  than  on  purely 
theoretic  grounds  was  desirable.  The  point  usually  chosen  for  the  division 
of  the  stomach  is  vertically  below  the  right  margin  of  the  esophagus  (approx- 
imately). 

The  only  remaining  point  is  concerned  with  the  section  of  the  duodenum.  It 
has  long  been  well  recognized  by  pathologists  that  the  duodenum  is  very  seldom 
invaded,  and  never  invaded  extensively  by  a  pyloric  cancer.  The  removal  of  the 
first  part  of  the  duodenum  is  ample  to  insure  that  all  growth  on  that  side  is  removed. 
The  lymphatic  glands  which  must  be  removed  include  those  along  the  lesser  curva- 
ture in  the  gastrohepatic  omentum,  and  those  along  the  greater  curvature,  especially 
in  the  pyloric  region,  where  they  are  numerous.  After  the  stomach  has  been  re- 
moved, glands  can  also  be  removed  from  the  upper  border  of  the  pancreas  without 
difficulty.  In  one  of  my  own  cases  the  glands,  which  were  not  laid  bare  until  the 
visceral  removal  was  complete,  were  unusually  large,  but  were  taken  away  from 
the  front  of  the  aorta  and  vena  cava  above  the  pancreas,  without  difficulty.  After 
the  removal  of  the  diseased  mass  is  complete  a  careful  search  is  made  in  all  the  parts 
where  glandular  infection  is  likely  to  have  occurred,  and  glands,  if  enlarged,  are 
removed.  It  must  always  be  remembered  that  in  malignant  disease  the  glandidar 
implication  does  not  always  follow  anatomic  lines  strictly,  for  when  the  lymphatic 
current  is  checked  in  one  direction  a  retrograde  current  occurs.  In  the  case  of  my 
own,  already  referred  to,  where  many  glands  along  the  pancreas,  especially  at  its  duo- 
denal end,  were  removed,  the  patient  is  well  and  free  from  recurrence  four  years  and 
nine  months  after  the  operation. 

Partial  Gastrectomy. 

Such,  then,  are  the  principles  of  the  operation  of  partial  gastrectomy  for  carci- 
noma pylori :  the  following  are  the  details  of  its  performance : 

The  abdomen  is  opened  through  a  small  central  or  slightly  lateral  incision  and 
the  extent  and  connections  of  the  growth  explored.  If  a  removal  of  the  carcinoma 
is  possible,  the  incision  is  rapidly  enlarged  to  the  fullest  extent — about  S  inches — 
and  the  stomach  and  duodenum  fully  exposed.  The  general  peritoneal  cavity  is 
packed  off  as  usual  with  two  layers  of  moist  hot  swabs,  an  outer  very  large  and  an 
inner  smaller,  which  is  changed  from  time  to  time  as  is  found  necessary.  The 
operation  will  be  rendered  easier  and  some  loss  of  blood  will  be  prevented  by  a 
preliminary  ligature  of  the  vessels  before  any  of  their  branches  are  cut.     The  first 

'  Moynihan,  B.  G.  A.:  "The  Operative  Treatment  of  Cancer  of  the  Pyloric  Portion  of  the 
Stomach,"  Chn.  Soc.  Trans.,  1901,  xxxv,  84. 


356  OPERATIOXS  UPON  THE  STOMACH. 

step  in  the  operation  is  the  hgation  of  the  coronary  artery.  The  vessel  is  secured 
as  it  approaches  the  lesser  curvature  of  the  stomach  at  its  highest  accessible  point. 
In  order  so  to  ligature  it,  the  stomach  is  pulled  well  downward  until  the  upper  part 
of  the  gastrohepatic  omentum  is  made  taut,  and  the  liver  is  forcibly  elevated  by  the 
hand  of  an  assistant.  The  vessel  can  be  seen  or  felt.  It  is  surrounded  by  a  catgut 
ligature  (Xo.  4)  passed  in  a  large  curved  intestinal  needle.  The  ligature  embraces 
not  only  the  artery,  but  also  a  small  piece  of  the  gastrohepatic  omentum — the  falx 
coronaria — which  enfolds  it.  The  needle  is  passed  with  a  double  thread,  the  two 
portions  of  wliich  are  pulled  apart  and  ligatured  at  least  one-half  inch  from  each 
other;  the  vessel  is  cut  between  them.  The  incision  thus  made  in  the  gastrohepatic 
omentum  is  continued  just  on  to  the  lesser  curvature  of  the  stomach  at  the  point  where 
the  section  of  the  viscus  is  afterward  to  be  made.  The  upper  cut  end  of  the  vessel  re- 
tracts a  little  toward  the  esophagus.  In  placing  the  ligature  on  the  artery  it  is  desira- 
ble to  make  sure  that  it  lies  below  the  point  of  origin  of  those  branches  of  the  main 
trunk  which  are  given  off  to  the  lower  subdiaphragmatic  portion  of  the  esophagus. 

The  gastric  artery  being  safely  ligatured,  the  gastrohepatic  omentum  is  divided 
as  close  to  the  liver  as  possible,  along  a  line  which  extends  from  the  small  incision 
already  made  by  the  division  of  the  artery  to  the  duodenum.  In  many  cases  the 
gastrohepatic  omentum  is  extremely  thin  and  it  tears  through  readily,  even  unex- 
pectedly. If  it  is  thicker,  it  is  ligatured  off  in  two  or  three  bundles;  a  large  curved 
intestinal  needle  armed  with  catgut  being  passed  to  secure  a  portion,  which  is  at 
once  ligatured  and  divided.  ^\Tien  these  bundles  have  been  secured,  the  upper  end 
of  the  pylorus  will  be  reached,  and  it  is  here  that  the  superior  pyloric  artery  is  liga- 
tured. This  vessel  may  be  taken  alone,  or  the  occasional  common  trunk  for  it  and 
for  the  gastroduodenal  artery  may  be  secured.  If  the  vessels  come  separately  from 
the  hepatic  trunk,  as  is  the  rule,  the  superior  pyloric  artery  alone  is  taken,  the  liga- 
ture of  the  gastroduodenal  being  left  till  the  duodenum  is  divided. 

When  the  vessel  is  secured  by  a  catgut  ligature,  a  couple  of  fingers  of  the  left 
hand  are  passed  behind  the  stomach  in  order  to  free  any  adhesions  which  may  per- 
haps exist  between  it  and  the  pancreas. 

When  the  lesser  curvature  and  posterior  surface  of  the  stomach  are  free,  two 
or  three  hot  moist  swabs  are  packed  above  the  lesser  curvature  into  the  lesser  sac, 
so  that  the  posterior  wall  of  this  sac  is  completely  protected. 

The  left  index-finger  is  now  passed  from  above  the  pylorus  behind  the  first  part 
of  the  duodenum  and  is  made  to  project  at  its  lower  border.  The  finger  is  then 
pushed  through  the  great  omentum  here,  at  a  point  about  one  inch  beyond  the  py- 
lorus. Along  the  track  occupied  by  the  left  index-finger  two  pairs  of  clamps  are 
now  passed  upward  side  by  side.  The  distal  clamp  is  rubber-covered;  the  proxi- 
mal, about  one-half  inch  away  from  it,  has  naked  blades.  When  both  are  securely 
placed,  the  duodenum  is  divided  between  them  (Fig.  5S6).  The  proximal  clamp 
is  pressed  home  as  tightly  as  possible,  but  in  the  subsequent  manipulations  it  may 
possibly  be  loosened.  To  prevent  this,  a  couple  of  stitches  are  passed  above  and 
below,  through  all  the  coats  of  the  duodenum,  and  are  tied  over  the  clamp.     This 


PARTIAL    GASTRECTOMY. 


357 


clamp  is  now  wrapped  round  with  hot  moist  gauze,  so  that  contact  with  the  cut 
mucous  surface  is  impossible. 

The  distal  cut  end  of  the  duodenum  may  now  be  closed,  or  if  it  is  thoudit  that 
subsequent  union  of  it  to  the  posterior  surface  of  the  stomach  will  be  possible,  it 
may  be  left  for  the  present  securely  wrapped  in  a  hot  moist  gauze  swab.  The 
closure  of  the  duodenum  may  be  effected  by  a  double  layer  of  sutures,  one  throuo-h- 


^^-'\-  e/ziD^oic  vess. 


Fig.  586. — Partial  Gastrectomy  for  Carcinoma  of  the  Pylorus. 
The  figure  shows  application  of  the  clamps  to  the  duodenum  with  line  between  them  where  division  is  made; 
the   gastroduodenal  artery  is  ligated  and  the  gastrohepatic  omentum  tied  off.     The  figure  also  shows  the  line  of 
division  of  the  gastrocolic  omentum,  the  points  for  hgating  the  vessels,  and  the  Hne  for  division  of  the  stomach. 


and-through,  taking  all  the  coats,  the  other  a  seromuscular  suture ;  or  the  cut  end 
may  be  surrounded  by  a  purse-string  suture  and  infolded,  a  supporting  serous  suture 
being  then  applied. 

The  stomach,  which  has  been  freed  along  the  lesser  curvature  and  at  the  duo- 
denum, can  now  be  lifted  well  out  of  the  abdomen,  and  the  subsequent  manipula- 


358 


OPERATIONS  UPON  THE  STOMACH. 


tions  easily  performed.  The  next  step  is  to  secure,  if  this  has  not  been  already  done, 
the  gastroduodenal  artery.  To  do  this,  the  clamp  on  the  duodenum  is  pulled  for- 
ward and  to  the  left  to  raise  the  pylorus  from  the  pancreas  behind.  The  vessel 
is  then  found  in  the  pancreatico-duodenal  recess.  It  is  ligatured  in  two  places  and 
divided  between. 

The  division  of  the  great  omentum  is  then  performed;  and  of  all  the  steps  in  the 
operation  this  is  perhaps  the  one  which  calls  for  the  greatest  care,  for  it  is  at  times 


Fig.  587. — Partiai-  Gastrectomy  for  Carcinoma  of  the  Pylorus. 
The  duodenal  and  the  stomach  openings  are  shown  sutured  with  continuous  through-and-through  sutures. 

difficult  to  avoid  wounding  the  middle  colic  artery,  and  damage  to  this  vessel  in- 
volves the  risk  of  gangrene  of  the  transverse  colon.  The  omentum  must  be  cut 
through  below  the  gastro-epiploia  vessels,  for  it  is  along  these  that  the  glands  lie, 
and  the  glands  must  be  removed  with  the  stomach.  The  omentum  is  secured  in 
sections,  either  at  once  by  hgature  with  catgut,  or  by  a  series  of  forceps,  one  placed 
beyond  the  other.  The  parts  gripped  in  each  forceps  are  then  separately  ligatured. 
It  is  quicker  to  display  each  portion  to  be  ligatured  upon  the  left  index-finger  which 


PARTIAL   GASTRECTOMY. 


359 


lies  behind  the  omentum  in  the  lesser  sac,  to  pass  a  curved  needle  around  the  part 
so  made  plain,  and  at  once  to  tie  and  cut  through  the  section.  The  next  inch  or 
so  of  the  omentum  is  then  displayed  and  similarly  ligatured,  and  so  on  until  that 
point  on  the  greater  curvature  is  reached  which  has  previously  been  determined 
upon  as  the  limit  of  the  resection.  This  being  done,  the  whole  mass  of  the  loosened 
growth  with  the  pyloric  portion  of  the  stomach  is  then  taken  in  the  left  hand  and 
held  well  forward,  so  that  both  surfaces  of  the  stomach  are  seen,  while  a  large  clamp 
(Kocher's  special  clamp,  or  my  own  largest  stomach  clamp)  is  then  applied  from  the 


Fig.  588. — Partial  Gastrectomy  for  Carcixoma  of  the   Pylorus. 
The  operation  is  completed;    the  sutured  stomach  is  shown  infolded  by  means  of  the  continuous  Dupuytren 
atitch,  the  Halsted  stitch  being  shown  at  the  upper  and  lower  ends.     The  duodenal  end  has  been  infolded  by  means 
of  Halsted  sutures.     The  position  of  the  posterior  gastro-enterostomy  is  shown. 

lesser  curvature  just  below  the  esophagus  to  the  greater  curvature  at  the  point  which 
has  been  reached  in  the  omental  ligation.  This  clamp  has  its  blades  covered  with 
rubber.  It  is  closed  sufficiently  to  insure  a  firm  grip  upon  the  stomach.  About 
half  an  inch  beyond  it  a  similar  naked  clamp  is  applied  and  pressed  home  as  firmly 
as  possible.  Between  these  two  clamps  the  stomach  is  now  divided.  At  first  the 
serous  and  muscular  coats  only  are  divided,  back  and  front,  and  then  subsequently 
the  mucous  coat.  If  the  division  of  all  the  coats  is  simultaneous,  the  mucosa  is  apt 
to  pout  a  httle  obtrusively.     A  difficulty  is  sometimes  encountered  at  the  lesser  cur- 


360  OPERATIONS  UPON  THE  STOMACH. 

vature  at  this  point  owing  to  its  tendency  to  withdraw  from  the  clamp.  If  it  should 
offer  to  do  this,  a  couple  of  clips  may  be  placed  upon  it,  distal  to  the  clamp,  or,  what 
is  better,  the  through-and-through  suture  is  started  at  once  at  this  end. 

The  sutures  which  are  now  passed  to  close  the  stomach  are  two — an  inner,  which 
is  occluding  and  hemostatic,  embraces  all  the  coats;  an  outer,  which  infolds  the 
inner,  is  seromuscular  only.  The  inner  suture  may  be  of  No.  2  iodized  catgut,  or 
of  Pagenstecher  thread;  the  outer  should  be  of  thread.  Both  are  passed  with  a 
curved  needle.  (Some  operators  here,  as  elsewhere,  prefer  a  straight  needle,  but 
the  curved  needle,  when  one  is  accustomed  to  it,  is  the  speedier.)' 

The  inner  suture  commences  at  the  lesser  curvature,  where  it  is  securely  knotted, 
and  continues  uninterruptedly  to  the  greater  curvature.  I  prefer  the  ordinary  con- 
tinuous through-and-through  suture,  for  bleeding  almost  certainly  occurs  from  the 
cut  surface  of  the  stomach  when  the  clamp  is  loosened,  and  if  the  mucosa  is  infolded 
by  a  Connell  suture  the  blood  escapes  into  the  stomach;  whereas,  by  the  suture  I 
use,  the  mucosa  is  not  infolded  but  only  apposed,  and  bleeding  from  it  is  at  once 
perceived  and  easily  arrested.  The  clamp  is  now  loosened  from  the  stomach  and 
any  bleeding  points  separately  secured  by  a  through-and-through  stitch.  The  next 
point  is  to  make  certain  that  the  upper  and  lower  parts  of  the  cut  stomach  are  well 
infolded.  This  is  not  entirely  easy,  owing  to  the  thickness  and  retraction  of  the 
stomach.  I  therefore,  before  beginning  the  outer  continuous  supporting  stitch, 
usually  pass  a  Halsted  suture  at  the  extreme  upper  end,  and  sometimes  also  at  the 
extreme  lower  end  of  the  incision.  When  the  edges  at  these  parts  are  well  rolled 
in,  the  continuous  Dupuytren  linen  stitch  is  passed  from  the  lesser  to  the  greater 
curvature.  The  stomach  when  now  inspected  shows  a  suture  hue  extending  from 
within  half  an  inch  of  the  end  of  the  esophagus  to  the  greater  curvature;  the  line 
of  section  seems  a  direct  continuation  downward  from  the  right  margin  of  the  gullet. 

At  this  stage  in  the  operation  it  only  remains  to  restore  the  continuity  of  the  in- 
testinal canal.  This  may  be  done  in  three  ways:  (1)  By  uniting  the  cut  end  of 
the  stomach,  reduced  in  size  by  suture,  to  the  cut  end  of  the  duodenum  ("  Billroth's 
first  method").  (2)  By  closing  both  ends  and  performing  a  separate  gastro- 
enterostomy ("Billroth's  second  method").  (See  Fig.  588.)  (3)  By  closing  the 
stomach  and  uniting  the  cut  end  of  the  duodenum  to  the  posterior  surface  of 
the  stomach    ("Kocher's  method"). 

Some  operators  perform  all  three  methods  in  different  circumstances.  I  prefer 
Billroth's  "second  method,"  for  if  a  free  removal  of  the  stomach  and  duodenum 
has  been  made,  it  is  often  difficult  and  sometimes  impossible  to  secure  an  end-to-end 
anastomosis.  The  approximation  of  the  duodenum  to  the  stomach  is  made  easier 
after  the  duodenum  has  been  "mobilized"  by  stripping  up  the  peritoneum  on  its 
outer  side. 

In  certain  cases  the  operative  procedure  may  be  varied  from  this.  The  gastro- 
enterostomy may  be  performed  first,  a  part  of  the  stomach  being  chosen  that  would 
be  left  if  a  resection  were  done.  Then  when  this  is  completed  the  resection  may  be 
performed  in  the  manner  already  described,  if  the  patient's  condition  justifies  it. 


GASTROTOMY.  361 

Or  the  gastro-enterostomy  may  be  done  after  the  omenta  and  the  duodenum  are 
divided  and  just  before  the  stomach  is  cut  through.  In  a  doubtful  case  the  re- 
section may  be  postponed  for  two  or  three  weeks;  during  this  time  the  patient, 
taking  food  freely,  will  gain  in  health  and  strength  and  be  the  better  able  to  with- 
stand the  removal  of  the  growth.  It  is  said  that  patients  are  reluctant  to  face  a 
second  operation  when  they  are  feeling  so  much  better  after  the  first,  but  I  have 
never  encountered  any  opposition  to  such  a  course. 

Carcinoma  of  the  Body  of  the  Stomach. — There  are  cases,  few  in  number,  it  is 
true,  in  which  the  growth  begins  in  the  body  of  the  stomach  and  causes  an  hour- 
glass constriction.  In  such  cases  the  affected  area  may  be  cut  out,  and  the  openings 
on  each  side  closed  by  suture.  The  details  of  the  operation  follow  the  lines  laid 
down  above. 

Carcinoma  of  the  cardiac  orifice  of  the  stomach  does  not  lend  itself  to  successful 
radical  treatment.  In  all  such  cases  gastrostomy  or  jejunostomy  when  the  growth 
has  extensively  invaded  the  stomach  are  alone  possible  as  palliative  measures. 

GASTROTOMY. 

Gastrotomy  is  the  operation  in  which  the  stomach  is  opened  for  the  purpose  of 
removing  from  it,  or  from  the  lower  end  of  the  gullet,  a  foreign  body  impacted 
therein,  or  with  the  object  of  investigating  the  interior  in  cases  of  ulcer  attended  by 
bleeding.  It  is  also  performed  in  rare  instances  of  stenosis  of  the  esophagus  when 
a  dilatation  of  the  stricture  from  below  is  thought  necessary.  When  these  purposes 
are  fulfilled,  the  wound  in  the  stomach  is  closed  and  the  viscus  is  returned  within  the 
abdomen. 

1.  Gastrotomy  for  the  Removal  of  Foreign  Bodies  from  the  Stomach. — 
This  is  one  of  the  most  ancient  of  the  operations  upon  the  stomach.  The  first  case 
recorded  was  operated  upon  by  Mathis  in  1602;  the  patient  was  a  juggler,  who  fifty 
days  before  had  swallowed  a  knife.  Adhesion  of  the  stomach  to  the  anterior  wall 
was  secured  by  the  application  of  "irritant  plasters,"  and  through  the  adherent 
wall  the  knife  was  removed.  The  result  was  successful.  The  following  extract 
from  "Evelyn's  Diary"  is  of  interest:  "But  amongst  all  the  rarities  of  this  place 
(Leyden),  I  was  much  pleased  with  their  anatomy  school,  theatre,  and  repository 
adjoining,  which  is  well  furnished  with  natural  curiosities:  skeletons  from  the 
whale  and  elephant  to  the  fly  and  spider,  which  last  is  a  very  delicate  piece  of  art 
to  see  how  the  bones  (if  I  may  so  call  them  of  so  tender  an  insect)  could  be  separated 
from  the  mucilaginous  parts  of  that  minute  animal.  Amongst  a  great  variety  of 
other  things  I  was  shewn  the  knife  newly  taken  out  of  a  drunken  Dutchman's  guts 
by  an  incision  in  his  side  after  it  had  slipped  from  his  fingers  into  his  stomach. 
The  pictures  of  the  chirurgeon  and  of  his  patient,  both  living,  were  there. " 

Cases  to  the  number  of  twenty-six  were  collected  by  Crede.^  ^Maurice  Richardson^ 

^  Crede,  B.:    "Gastrotomie  wegen  Freindkorper,"  Archiv  f.  klin.  Chir.,  1886,  xxxiii.  574. 
^  Richardson,  Maurice  H.:    "A  Case  of  Gastrotomy,  Digital  Exploration  of  Esophagus  and 
Removal  of  Plate  of  Teeth;   Recovery,"  Boston  Med.  and  Surg.  Jour.,  1886,  ii,  567. 


362  OPERATIONS  UPON  THE  STOMACH. 

published  a  list  of  thirty-two  cases.  The  most  important  paper  is  that  of  Frieden- 
wald  and  Rosenthal/  wherein  all  the  cases  from  the  literature  are  abstracted, 
and  others  not  before  published  are  also  given,  to  the  total  number  of  ninety.  For 
many  of  the  following  particulars  I  am  indebted  to  this  article. 

In  the  ninety  collected  cases  one  foreign  body  was  found  in  sixty-eight  instances, 
more  than  one  in  the  remainder.  The  majority  of  the  foreign  bodies  were  of  metal, 
and  were  swallowed  either  in  fits  of  insanity  or  during  acts  of  display  for  the  purposes 
of  obtaining  a  livehhood.  The  most  common  among  them  were  nails,  knives,  spoons, 
forks,  safety-pins,  hair-balls,  stones,  buttons,  and  keys.  The  most  remarkable 
foreign  body  was  a  complete  pair  of  braces.  Kortmann^  relates  the  case  of  a  painter 
who  had  two  shellac  stones  weighing  670  grams  in  the  stomach  for  over  sixteen 
years.  Hair-balls,  which  often  are  of  large  size,  forming  as  it  were  a  cast  of  the 
stomach,  are  made  up  of  hair  pulled  by  the  patient  from  her  own  head,  or,  rarely, 
of  the  hairs  from  animals,  notably  the  cow  or  the  horse.  The  hair  is  closely  felted, 
being  worked  up  into  a  soHd  mass  by  the  action  of  the  stomach.  The  ages  of  the 
patients  in  the  ninety  cases  are  as  follows : 

Males.  Females. 

Under  1  year , 0  1 

1  to  10  years •  •  •  0  3 

10  to  20      "     7  7 

20  to  30      "     15  15 

30  to  40      "     14  6 

40  to  60      "      5  3 

60  to.  80      "     1  1 

Adhesions  were  present  in  thirteen  cases;  in  six  an  abscess  was  found  to  point  on 
the  anterior  abdominal  wall;  in  three  perforation  of  the  stomach,  ending  fatally, 
was  caused. 

The  symptoms  caused  by  a  foreign  body  are,  as  a  rule,  few  and  devoid  of  special 
significance.  In  some  a  tumor  has  been  observed,  its  exact  nature  being  revealed 
only  at  the  time  of  operation.  The  symptoms  most  usually  recorded  are  pain, 
vomiting,  loss  of  appetite,  weakness.  Kranzle,  quoted  by  Friedenwald,  remarks: 
"The  condition  of  the  patients  shortly  before  the  operation  is  in  no  wise  propor- 
tionate to  the  severity  of  the  changes  which  are  found  in  the  stomach,  which  shows 
plainly  how  Httle  one  can  depend  upon  the  stomach  symptoms  in  these  cases  in 
forming  a  picture  of  how  far  the  stomach  has  become  actually  diseased. "  Symp- 
toms, then,  are  few  and  inconspicuous.  A  locahzed  tumor  is  usually  the  cause  of 
operation.  Of  the  ninety  cases  recorded,  seventy-one  have  been  operated  upon  in 
recent  years,  and  the  success  has  been  considerable,  over  90  per  cent,  of  the  patients 
recovering. 

Operation. — The  operation  is  commenced  by  opening  the  abdomen  through  a 
long  median  or  slightly  lateral  incision.  The  stomach,  being  exposed,  is  drawn 
well  into  the  wound  and  the  peritoneal  cavity  is  walled  off  in  the  usual  way  by  a 

'  Friedenwald,  Julius,  and  Rosenthal,  L.  J.:  "A  Statistical  Report  of  Gastrotomies  for  Re- 
moval of  Foreign  Bodies  from  the  Stomach,"  New  York  Med.  Jour,  and  Phila.  Med.  Jour.,  1903, 
ii,  110. 

^Vonnegut;  "  Ein  Fall  von  Schellacksteinen  in  menschlichen  Magen,"  Deut.  med.  Woch., 
1897,  xxiii,  26,  S.  418. 


GASTROTOMY.  363 

series  of  swabs  or  by  gauze.  A  vertical  incision  is  then  made  through  all  the  coats 
of  the  stomach,  the  incision  being  so  placed  as  to  avoid,  as  far  as  possible,  any  injury 
to  the  larger  branches  of  the  vessels.  Bleeding  is  always  free  and  is  arrested  by 
the  application  of  a  series  of  clips.  The  foreign  body  is  then  extracted  in  the  man- 
ner which  seems  best,  a  small  body  being  seized  in  forceps,  a  larger  mass  being 
turned  out  with  the  hand.  The  wound  in  the  stomach  is  then  closed  by  a  double  row 
of  continuous  sutures,  the  inner  embracing  all  the  coats,  and  infolding  the  mucosa, 
the  outer  seizing  only  the  serous  and  muscular  layers.  The  swabs  are  then  removed 
and  the  abdomen  closed. 

2.  Gastrotomy  for  the  removal  of  foreign  bodies  in  the  lower  end  of  the 
esophagus  had  been  performed  with  great  success  on  a  few  occasions.  The  best 
recorded  case  is  that  of  ]Maurice  Richardson.^  The  patient  was  a  man  who  had 
swallowed  a  denture  bearing  four  teeth,  eleven  months  before;  this  had  become 
impacted  in  the  lower  end  of  the  esophagus.  After  the  stomach  had  been  opened 
the  hand  and  forearm  were  inserted  into  the  stomach,  and  the  cardiac  orifice  of  the 
stomach  discovered.  The  plate  was  felt  impacted  about  2  inches  above  the  dia- 
phragm; it  was  detached  and  withdrawn,  and  the  stomach  wound  carefully  closed. 
The  case  proved  most  successful.  The  conclusions  with  regard  to  the  operation 
which  were  formulated  by  Richardson  were:  that  the  oblique  incision  below 
the  margin  of  the  ribs  is  the  best;  that  the  stomach  after  being  withdrawn  from  the 
abdomen  a  Httle  should  be  opened  to  the  right  of  the  convexity  of  the  lesser  gurve; 
that  the  assistant  by  traction  on  the  stomach  should  put  the  lesser  curvature  on  the 
stretch,  and  that  the  sidcus  so  formed  is  always  a  guide  to  the  cardiac  orifice. 

3.  Gastrotomy  for  Exploration  of  the  Stomach  Interior. — This  is  chiefly 
necessary  in  cases  of  hemorrhage  from  an  ulcer,  when  the  bleeding  is  recurring  in 
such  quantities  and  at  such  intervals  as  to  threaten  life.  It  has  also  been  per- 
formed in  cases  of  pedunculated  tumors  of  the  stomach  accessible  only  from  within. 

In  all  cases  of  exploratory  gastrotomy  it  is  essential,  as  first  pointed  out  by 
W.  W.  Keen,^  that  the  stomach  should  be  well  washed  out,  and  emptied,  and  before 
it  is  opened  it  should  be  brought  out  of  the  abdominal  cavity  and  well  walled  off  by 
gauze,  so  that  the  operation  is  practically  extraperitoneal. 

The  stomach  is  opened  on  its  anterior  surface  by  either  a  vertical  or  a  transverse 
incision.  The  latter  is  preferable,  for  though  hemorrhage  is  perhaps  more  severe, 
a  far  better  view  of  the  interior  of  the  organ  can  be  obtained.  The  cut  edges  of  the 
stomach  are  held  wide  apart  by  chps  or  fine  vulsella,  and  any  fluid  seen  in  the  stom- 
ach is  mopped  away.  A  speculum  is  then  introduced  into  the  stomach  and  the 
mucosa  inspected,  or,  as  is  far  better,  a  small  incision  is  made  through  the  gastro- 
colic omentum,  or  even  through  the  transverse  mesocolon,  and  the  mucosa  of  the 
stomach  inverted  through  the  anterior  incision.  As  the  fingers  are  moved  from  one 
part  of  the  stomach  to  another  the  greater  part  of  the  mucous  membrane  is  passed 

^Richardson,  Maurice  H.:  "A  Case  of  Gastrotomy,  Digital  Exploration  of  Esophagus  and 
Removal  of  Plate  of  Teeth,  Recovery,"  Boston  Med.  and  Surg.  Jour.,  1886,  ii,  567 

^Keen,  W.  W.:  Cartwright  Lectures  on  the  Surgery  of  the  Stomach,  1898,  Phila.  Med.  Jour., 
1898,  i,  829. 


364  OPERATIONS    UPON   THE    STOMACH. 

under  review.  If  an  ulcer  is  found,  it  is  excised  or  cauterized,  or  sutured  from  witliin 
as  seems  best.  It  is  generally  necessary  also  to  suture  the  area  involved  from  the 
serous  surface  only,  a  few  infolding  Lembert  sutures  being  used. 

4.  Gastrotomy  for  the  purpose  of  assisting  in  the  dilatation  of  an  esopha- 
geal stricture  has  been  occasionally  found  very  useful.  Gissler^  collected  ten  cases 
and  Kendal  Franks"  twenty-one  cases,  all  the  patients  recovering.  Dilatation  can 
be  done  by  two  methods:  "  (1)  By  immediate  dilatation  or  division,  if  the  stricture 
is  suited  to  this  procedure.  In  this  case  the  stomach  and  the  abdomen  are  immedi- 
ately closed.  If,  however,  a  large  portion  of  the  esophagus  is  constricted  and  repeated 
dilatation,  a  little  at  a  time,  is  required,  then  (2)  a  temporary  gastric  fistula  is 
established,  and  later,  when  the  dilatation  is  accomphshed,  the  fistula  either  closes 
spontaneously  or  is  closed  by  a  plastic  operation. "  ^  Hagenbach*  opened  the  stom- 
ach and  attached  it  to  the  anterior  abdominal  wall.  Then  the  patient  was  given 
a  small  shot,  threaded  on  a  string,  to  swallow.  This  when  it  reached  the  stomach 
was  drawn  out  of  the  fistula,  and  to  the  fine  thread  a  stout  one  was  attached,  and 
drawn  upward  to  the  mouth;  by  means  of  the  stronger  thread  bougies  were  pulled 
through  the  stricture.  Abbe^  has  suggested  a  very  ingenious  method.  A  string 
is  passed  through  the  stricture  from  the  mouth,  or,  better,  from  an  opening  made 
into  the  esophagus  from  the  neck,  and  brought  out  through  a  gastric  fistula.  The 
stricture  is  then  put  on  the  stretch  by  a  bougie  passed  into  it,  and  the  string  is  pulled 
backward  and  upward,  sawing  into  the  stricture.  Kendal  Franks  passed  Otis' 
urethrotome  upward  into  the  stricture  through  the  cardiac  orifice  and  dilated  in  that 
way. 

A  few  cases  of  gastrotomy  for  the  removal  of  pedunculated  tumors  are  recorded. 
Chaput*^  gives  details  of  a  case  of  pedunculated  adenoma  excised  from  the  posterior 
wall  in  this  way.  Lyman^  opened  the  stomach  of  a  man  of  sixty  by  an  incision 
5^  inches  long,  and  removed  a  solid  mass  of  adenocarcinoma  whose  diameter  was 
5  inches.  Bennett^  removed  a  simple  papilloma  that  occluded  the  pylorus  from 
time  to  time,  and  led  to  intermittent  dilatation  of  the  stomach.  The  patient  was 
cured. 

1  Gissler,  J.:  "Ueber  die  retrograde  Dilatation  von  Oesopliagus-Stricturen,"  Beit.  z.  klin. 
Chir.,  1892,  viii,  109. 

2  Franks,  Kendal:  "Fibrous  Stricture  of  the  (Esophagus  Treated  by  Gastrotomy  and 
Retrograde  Dilatation,"  Ann.  of  Surg.,  xix,  385. 

^  Keen:  Loc.  cit. 

^Hagenbach,  Carl:  " Casuistische  Beitrage  zur  retrograden  Dilatation  von  Oesophagus- 
Stricturen,"  Correspondenzblatt.  f.  Schweiz.  Aertzte,  1889,  Nr.  5. 

5  Abbe,  Robert:  "A  New  and  Safe  Way  of  Cutting  CEsophageal  Strictures,"  Med.  Rec, 
1893,  xhii,  225. 

*  Chaput,  H.:  "Adenome  de  la  paroi  posterieure  de  I'estomach,"  etc..  Bull,  et  Mem.  Soc. 
de.  Chir.,  1894,  xx,  452. 

'  Lyman,  C.  B.:  "Report  of  a  Case  of  Gastrotomy  for  Removal  of  a  Pedunculated  Carcinoma 
of  the  Stomach,"  Ann.  of  Surg.,  1896,  xxiv,  310. 

^  Bennett,  W.  H.:  "A  CHnical  Lecture  on  Some  Cases  of  Dilatation  of  the  Stomach  Con- 
sidered from  a  Surgical  Aspect,"  Brit.  Med.  Jour.,  1900,  i,  243. 


GASTROSTOMY.  365 

GASTROSTOMY. 

Gastrostomy  is  the  operation  in  which  an  artificial  opening  is  made  directly  into 
the  stomach  for  the  purpose  of  allowing  the  introduction  of  food,  in  cases  where  the 
esophagus  is  rendered  impassable  by  disease,  or  in  order  to  permit  an  esophageal 
stricture  to  be  treated  by  certain  special  methods,  e.  g.,  Abbe's,  Kraske's. 

History. — The  operation  was  suggested,  though  never  performed,  by  Egebero-, 
a  Norwegian  mihtary  surgeon.  He  spoke  of  the  possibility  of  making  "an  opening 
into  the  stomach  for  the  purpose  of  injecting  a  sufficient  quantity  of  food,  or  for 
treating  an  esophageal  stricture  from  below."  The  first  operation  upon  man  was 
performed  on  November  13,  1849,  by  Sedillot;  the  patient  died  in  a  few  hours.  In 
this  operation  the  stomach  was  opened  at  once,  but  in  a  second  case,  operated  upon 
on  January  21,  1853,  Sedillot  divided  the  operation  into  two  stages,  attaching  the 
stomach  to  the  abdominal  wall  first,  and  allowing  it  to  become  fixed  there  before 
opening  it.  In  1875  Sidney  Jones,  of  St.  Thomas's  Hospital,  operated  with  success, 
the  patient  living  twenty  days.  Verneuil  in  1876  operated  upon  a  patient  who  lived 
for  sixteen  months.  In  its  early  days  the  operation  was  a  most  unsatisfactory  one, 
for  the  opening  was  both  an  inlet  and  an  outlet;  food  could  be  introduced  freely 
into  the  stomach,  but  with  equal  freedom  it  escaped;  gastric  juice  also  leaked  from 
the  wound  and  made  haste  to  digest  the  skin  of  the  abdomen,  which  became  in- 
tensely sore.  Upon  the  exquisitely  tender  surface  of  the  abdomen  leakage  was 
constantly  pouring,  and  the  most  intense  suffering  was  caused.  In  recent  years 
a  variety  of  methods  have  been  suggested,  having  for  their  object  the  making  of 
an  opening  which  shall  be  valvular,  allowing  ready  entrance  to  the  food,  but  offering 
an  obstacle,  wholly  or  almost  wholly,  impassable  to  the  fluid  contents  of  the  stomach. 

Conditions  for  which  the  Operation  may  be  Done.— 1.  Malignant  Disease 
of  the  Esophagus. — This  is  the  chief  indication.  In  these  cases  the  patient  is  suffer- 
ing gradual  starvation  by  reason  of  the  increasing  narrowness  of  the  esophagus. 
The  growth  in  the  gullet  may  be  at  the  upper  end,  at  the  lower  end,  or  at  the  point 
where  the  left  bronchus  crosses  just  below  the  bifurcation  of  the  trachea.  It  is 
probable  that  the  latter  is  the  most  frequent,  though  it  is  not  seldom  stated  that  the 
lower  end  is  most  commonly  affected;  this  is  due  to  the  fact  that  those  cases  of 
growth  in  the  cardiac  end  of  the  stomach  are  also  included.  The  latter  are,  how- 
ever, glandular  carcinomata,  the  esophageal  growths  being  squamous  carcinomata; 
in  rare  instances  columnar  epithelioma  is  found,  having  its  origin  no  doubt  in  the 
epithelium  of  the  esophageal  glands. 

2.  Carcinoma  of  the  Cardiac  End  of  the  Stomach. — The  symptoms  caused  by 
this  are  similar  to  those  which  result  from  cancer  of  the  esophagus,  but  a  bougie 
will  pass  usually  over  15  inches  beyond  the  teeth  before  being  arrested  when  the 
obstruction  is  in  the  stomach. 

3.  Simple  Stricture  of  the  Esophagus. — This  is  almost  invariably  fibrous  in 
character,  and  results  from  the  cicatricial  contraction  occurring  in  ulcers  which 
have  been  caused  by  the  swallowing,  by  accident  or  with  suicidal  intent,  of  caustic 


366 


OPERATIOXS    UPON    THE    STOMACH. 


fluids.  The  position  in  which  these  strictures  are  found  is  identical  with  that  which 
obtains  in  cases  of  mahgnant  disease;  but  the  lower  end  of  the  gullet  is  without  doubt 
much  more  commonly  affected  than  any  other  part.  In  simple  stricture  of  the 
esophagus  the  operation  may  be  performed  for  one  of  two  reasons:  either  to  permit 
of  retrograde  dilatation  of  the  stricture  by  Abbe's  method  or  Kraske's  method,  or 
to  allow  the  patient  to  be  fed  artificially. 

4.  In  cases  ofBecent  Scalding  of  the  Esophagus  or  Siomach  hij  Caustics. — In  these 

cases  the  operation  of  gastrostomy  is  combined  with  that  of  gastro-enterostomy 

q.  v.).     A  similar  combination  of  the  two  operations  has  been  suggested  for  cases 

of  acute  hemorrhage  from  ulcer        .^  of    the   stomach;     and    by  Neumann 

for  cases  of  intense  hyperacidity. 

The  most  debatable  point  in  con- 
nection with  the  operation  of  gastros- 
tomy in  cases  of  malignant  disease 
of  the  esophagus  or  cardia  has  refer- 
ence to  the  stage  of  the  disease  in 
which  the  operation  should  be  per- 
formed. In  earlier  days  the  opera- 
tion was  attended  by  such  grave  dis- 
advantages that  it  was  only  when  the 
patient  was  on  the  brink  of  starvation 
that  the  surgeon  felt  entitled  to  urge 
the  performance  of  the  operation. 
But  with  the  modern  "valve"  opera- 
tions there  can  be  no  hesitancy  in 
ad^^sing  operation  as  soon  as  the  pa- 
tient is  beginning  seriouslv  to  suffer 
from  lack  of  food.  When  the  diet  by 
slow  degrees  has  l)een  curtailed  till 
only  fluids  are  taken,  and  these  with 
some  difficulty,  on  account  of  regurg- 
itation, then  operation  must  no  longer 
be  delayed.  If  the  patient  suffers  much  from  the  constant  regurgitation  of  mucus, 
— and  this  is  sometimes  most  distressing, — operation  may  be  performed  earlier. 
It  is  better  to  perform  gastrostomy  too  early  than  too  late,  for  the  discomforts  and 
risks  of  the  operation  in  the  former  case  are  neghgible.  If  need  be,  the  operation 
can  be  performed  under  local  anesthesia.  There  are  several  methods  of  perform- 
ing gastrostomy;  the  chief  of  these  are:  (\ )  Franck's  method  ("Sbanajew-Franck," 
"Albert-Franc'k,"  or  "  Albert-Franck-Kocher");  (2)  Witzel's  method;  (3)  Senn's 
method;   (4)   Depage's  method. 

Franck's  Operation. — An  incision  about  2  inches  in  length  is  made  parallel  to 
the  left  costal  margin,  and  one  inch  below  it,  just  below  the  edge  of  the  liver.  The 
incision  is  made  in  a  vertical  direction  by  many  surgeons  and  is  equally  satisfactory. 


J^^e^'^- 


Fig.  589. — Franck's  Method  of  Gastrostomy. 


GASTROSTOMY. 


367 


Fig.  590. 


Fraxck's  Method  of  G.^stros- 

TOMY. 


As  soon  as  the  abdomen  is  opened  the  stomach  is 
sought  and  a  part  of  its  anterior  wall  is  grasped 
and  pulled  well  up  into  the  wound,  until  a  cone- 
shaped  part  of  it  protrudes.  The  part  of  the 
stomach  pulled  out  is  as  near  the  cardia  as  pos- 
sible; it  is  fixed  at  its  base  to  the  parietal  perito- 
neum by  a  running  suture  or  bv  several  inter- 
rupted sutures  (Fig.  589).  A  .second  incision 
over  the  costal  margin  is  now  made,  about  f  to 
1  inch  in  length,  distant  about  one  inch  from  the 
margin.  Between  this  incision  and  the  original 
incision  the  skin  is  dis.sected  up  until  a  bridge  is 
left  bv  it,  free  at  each  side,  attached  at  each  end. 
Beneath  this  bridge  the  stomach  cone  is  passed 
until  its  apex  protrudes  through  the  second 
smaller  inci-sion,  where  it  is  fixed  by  three  or 
four  sutures.  The  original  wound  is  then  closed 
(Fig.  590).  The  nipple-hke  projection  of  the 
cone  is  then  opened  at  once  or  later,  and  a  cath- 
eter passed  for  feeding  purposes. 

Witzel's  Method. — The  object  of  this  operation  is  to  form  an  oblique  tunnel 

in  the  walls  of  the  stomach.  A  ver- 
tical incision  two  inches  in  length  is 
made  through  the  upper  part  of  the 
left  rectus,  and  the  muscle  split. 
The  anterior  wall  of  the  stomach 
is  pulled  well  into  the  wound,  and 
a  small  opening  made  into  it  about 
the  middle,  near  the  greater  curva- 
ture. A  tube  is  passed  into  this 
opening  and  fixed  by  a  catgut  suture. 
The  tube  is  then  laid  flat  upon  the 
surface  of  the  stomach,  and  a  suture 
is  taken  through  the  serous  and 
muscular  coats  of  it  from  one  side 
to  the  other  until  a  ridge  is  raised 
up  on  each  side,  and  the  ridges  meet- 
ing across  the  top  of  the  tube  bury 
it  in  a  gutter.  The  suture  begins 
about  vj  inch  beyond  the  point  where 
the  tube  enters  the  stomach,  so  that 
there  is  no  fear  of  leakage  there. 
The   method  is  a   most   satisfactory 


Fig.  591. — Witzel's  Method  of  Gastrostomy. 


one.     (See  Fig.  591.) 


368 


OPERATIONS  UPON  THE  STOMACH. 


The 


Fig.  592. — Senn's  Method  of  Gastrostomy. 


Senn's  Method  (E.  J.  Senn). — This  is  the  method  I  prefer  to  all  others;  it  is 

simple,  perfectly  effective  in  preventing  leak- 
age, and  is  more  rapidly  performed  than  any 
other.  A  vertical  incision  is  made  over  the 
left  rectus  muscle  near  its  outer  border,  com- 
mencing a  little  below  the  level  of  the 
tip  of  the  xiphoid  cartilage,  and  con- 
tinuing downward  for  about  2h  inches, 
fibers  of  the  rectus,  muscle  are  separ- 
ated, not  divided,  and  the  peritoneal  cavity 
is  opened.  If  the  separation  is  done  by  the 
finger  covered  by  gauze,  no  nerves  will  be 
divided.  The  stomach  is  then  sought  and  is 
easily  recognized.  It  is  said  that  the  trans- 
verse colon  has  been  mistaken  for  the  stomach 
and  has  been  opened;  one  would  think  that 
such  a  mishap  is  impossible,  for  there  is  not 
the  slightest  resemblance  between  the  two 
viscera.  The  stomach  is  generally  found  at 
once,  but,  owing  to  the  fact  that  it  is  often 
thin-walled  and  shrunken  from  long  suppres- 
sion if  its  normal  activity,  it  may  lie  flaccid  and  empty  at  the  back  of  the  stomach 
chamber,  with  the  transverse  colon  in  front 
of  it.  When  the  colon  is  displaced  down- 
ward, it  comes  at  once  into  view.  It  is 
picked  up,  drawn  forward  to  the  parietal 
incision,  and  a  portion  of  it,  as  far  removed 
as  possible  from  the  pylorus,  is  selected  for 
the  operation.  A  point  about  midway  be- 
tween the  lesser  and  the  greater  curvature  is 
chosen  for  the  site  of  the  opening  into  the 
stomach.  iVt  this  point  a  small  incision  is 
made  with  a  scalpel,  of  sufficient  size  to  ad- 
mit a  No.  10  or  12  Jacques  catheter  or  a  piece 
of  drainage-tube  of  about  the  same  diameter. 
The  catheter  or  tube  is  passed  into  the  stom- 
ach through  this  opening  for  a  distance  of 
about  two  or  three  inches,  and  is  then  fixed 
by  a  single  catgut  stitch  which  passes 
through  all  the  coats  of  the  stomach,  at  the 
edge  of  the  incision,  and  then  picks  up  a 
part  of  the  tube  (Fig.  592).  When  this  stitch  is  tightened,  the  tube  is  held  fast  and 
remains  so  held  until  the  catgut  is  absorbed — or  cuts  through — in  about  ten  days. 


Fig.    593. 


Senn's   Method    of   Gastrostomy. 
Second  Step. 


GASTROSTOMY. 


369 


The  tube  so  fixed  is  now  buried  in  an  inverted  cone  formed  from  the  walls  of  the 
stomach  by  the  insertion  of  three  purse-string  sutures.  The  first  purse-string  suture 
is  applied  in  a  circle  whose  center  is  the  tube,  and  whose  radius  is  about  half  an  inch. 
The  suture  picks  up  the  stomach-wall  at  about  six  points.  As  it  is  tightened,  the 
tube  is  depressed  into  the  stomach  by  an  assistant  whose  other  hand  holds  the  stom- 
ach steady,  so  that  when  tied,  the  suture  closely  embraces  the  tube.  A  second  suture 
is  now  introduced  at  a  distance  of  half  an  inch  from  the  tube,  picking  up  the  stom- 
ach wall  at  seven  or  eight  points.  As  it  is  tightened  and  tied,  the  tube  is  again 
pushed  inward  so  that  the  suture  again  embraces  the  tube  closely.  A  third,  and  if 
necessary,  a  fourth,  suture  can  be  similarly  introduced.  The  result  is  that  a  cone  of 
the  stomach  is  inverted  into  the  cavity  of  the  organ;  and  in  the  center  of  this  cone 
there  lies  the  tube  or  catheter,  closely  embraced  by 
the  outer  wall  of  the  stomach.  The  stitches  are 
all  tightened  with  sufficient  firmness  to  embrace, 
though  not  to  constrict,  the  tube.  When  the  last 
stitch  has  been  cut  short,  two  sutures  are  passed 
above  and  below  the  tube  in  order  to  fix  the 
stomach  to  the  parietal  peritoneum.  The  sutures 
include  the  posterior  sheath  of  the  rectus  and  par- 
ietal peritoneum  on  each  side,  and  pick  up  a  broad 
strip  of  the  stomach  about  |  inch  distant  from  the 
tube.  They  serve  to  draw  the  stomach  up  to  the 
parietal  incision  and  to  fix  it  there  firmly. 

Depage's  Method. — In  this  method  a  tube  is 
made  out  of  the  anterior  wall  of  the  stomach,  and 
through  it  the  food  is  conducted.  A  vertical  incis- 
ion through  the  rectus  muscle  is  made  and  the 
abdomen  opened.  A  large  part  of  the  stomach  is 
drawn  up  into  the  wound  and  is  stitched  all  round 
to  the  edge  of  the  parietal  peritoneum.  A  flap  with 
its  base  upward  is  then  cut  out  of  the  anterior  wall  of 

the  stomach.  This  is  done  by  pinching  up  a  fold  of  the  wall  between  long  pressure 
forceps,  and  cutting  along  the  edge  of  the  blades.  The  flap  is  then  turned  upward, 
and  the  incision  in  the  stomach  is  closed  by  a  continuous  suture  passed  at  first  only 
through  the  mucous  coat,  and  carried  up  along  the  flap  which  has  been  raised.  Out- 
side this  suture  a  second,  picking  up  the  serous  and  muscular  coats,  is  passed  at  first 
along  the  edge  of  the  wound  in  the  stomach  and  then  along  the  tube,  which  has  now 
a  complete  serous  covering.  The  canal  thus  made  is  fixed  to  the  abdominal  wound, 
or  may  be  passed,  if  long  enough,  beneath  a  bridge  of  skin,  as  in  Franck's  method. 

In  all  the  operations  it  will  be  found  that  the  stomach  is  small  and  contracted, 
the  result  of  long  curtailment  in  the  amount  of  food  w^hich  has  been  taken. 

After-treatment. — The  patient  may  be  fed  at  once  on  the  completion  of  the 
operation,  with  milk,  beaten  egg,  and  brandy.     As  a  rule,  food  should  then  be  given 
VOL.  II — 24 


Fig.    594. 


Senn's    Method    of   Gas- 
trostomy. 


370  OPERATIONS  UPON  THE  STOMACH. 

in  small  quantities  frequently,  because  of  the  small  size  of  the  stomach.  As  a  rule, 
6  ounces  every  three  hours  is  enough ;  to  be  later  increased  in  quantity,  the  intervals 
being  lengthened.  It  is  often  found  that  after  a  few  days  the  patient  can  swallow- 
better,  sometimes  very  much  better,  than  before  the  operation.  It  is  wise  to  allow 
patients  to  drink  a  little  of  their  favorite  beverage,  and  to  masticate  food  which 
may  be  ejected  afterward.  All  forms  of  fluid  may  be  given,  the  more  nutritious 
being  chosen ;  and  an  occasional  washing  out  of  the  stomach  through  the  tube  gives 
comfort. 

Prognosis. — The  immediate  results  of  the  operation  are  good.  I  have  only 
lost  one  patient  in  thirty-one  operations,  and  that  was  a  case  early  in  my  experience, 
performed  when  the  patient  had  not  swallowed  a  drop  of  fluid  for  several  days.  The 
ultimate  outlook,  of  course,  is  hopeless;  but  patients  live  their  days  in  comparative 
comfort,  free  from  the  torture  of  thirst.  The  operation  lengthens  the  patient's  life; 
but,  what  is  vastly  more  important,  it  brings  relief  from  suffering  and  from  the 
indescribable  horror  of  thirst  and  starvation. 


GASTROPEXY. 

Gastropexy  is  the  operation  by  means  of  which  the  stomach  which  has  fallen 
low  in  the  abdomen  is  replaced  is  its  normal  position  and  sutured  there. 

The  treatment  of  the  prolapse  of  the  stomach  by  operation  was  first  suggested 
by  Duret,^  of  Lille.  The  condition  of  descent  of  this  organ  may  exist  alone  or  it 
may  be  merely  a  part  of  that  general  enteroptosis  which  is  usually  described  as 
"  Glenard's  disease. "  Rovsing,  of  Copenhagen,  and  Beyea,  of  Philadelphia,  have 
given  special  attention  to  this  subject. 

Rovsing  describes  two  forms  of  gastroptosis :  (1)  That  which  he  describes  as 
"virginal,"  which  is  the  rarer,  but  which  is  the  more  important,  since  the  great  ma- 
jority of  cases  needing  operation  belong  to  this  class.  The  abdominal  wall  is  firm 
and  strong.  (2)  That  which  occurs  in  multiparous  women ;  it  is  often  accompanied 
by  considerable  prolapse  of  other  viscera,  causes  htde  pain,  and  is  often  relieved 
by  well-fitting  bandages. 

Bandages  are  of  no  value  in  the  "virginal"  form  because  the  abdominal  wall, 
being  sound,  does  not  allow  adequate,  properly  directed,  pressure  to  be  exerted  by 
any  external  appliance. 

Rovsing  has  operated  upon  forty-nine  cases;  forty-four  belonged  to  the  "vir- 
ginal" class,  five  to  the  "multiparoiis."  In  only  six  of  the  cases  was  there  gastric 
stasis.  All  the  padents  recovered  from  the  operation,  and  all  were  reheved,  with 
the  exception  of  one  case  where  there  was  also  a  narrowing  (unnoticed  at  the  time) 
of  the  duodenum  due  to  old  adhesions.  In  one  case  gastropexy  was  combined  with 
hepatopexy ;  in  another,  removal  of  the  extremity  of  an  enlarged  left  lobe  of  the  liver 
was  also  performed. 

The  cases  of  prolapse  of  the  stomach  alone  that  I  have  been  called  upon  to  treat 

'  Duret,  H.:  "  De  la  gastropexie,"  Rev.  de.  Chir.,  1896,  xvi,  421. 


GASTROPEXY.  371 

are  singularly  few,  not  more  than  three  in  all,  though  I  have  been  cognizant  of  the 
work  done  in  this  subject  by  Rovsing  and  others,  and  have  given  close  attention  to 
the  matter.  I  am  driven,  therefore,  to  the  belief  that  there  can  only  rarely  be  any 
need  for  surgical  treatment.  It  cannot  be  denied  that  the  majority  of  patients  who 
suffer  from  prolapse  of  the  stomach  are,  with  those  who  suffer  from  the  similar  con- 
dition affecting  the  kidney,  of  the  type  described  as  "neurotic."  It  is  not  the  mere 
descent  of  one  or  more  organs  that  is  the  disease,  but  rather  a  vice  in  all  the  parts 
which  derive  guidance  from  the  abdominal  sympathetic  nervous  system.  To  anchor 
one  organ  or  many,  in  such  circumstances,  is  of  little  value  unless  it  is  clear  that  the 
symptoms  of  which  the  patient  makes  complaint  are  in  some  measure  due  to  the  dis- 
placement of  that  organ  or  organs. 

The  following  methods  of  performing  the  operation  are  recognized :  (1)  Buret's 
method;   (2)   Beyea's  method;   (3)   Coffey's  method;   (4)  Rovsing's  method. 

The  preparation  of  the  patient  is  the  same  as  in  all  abdominal  operations. 

Duret's  Operation. — A  long  incision  is  made  in  the  abdominal  wall  from  the 
ensiform  cartilage  to  the  umbilicus,  down  to  the  peritoneum.  In  the  upper  part 
of  the  wound  the  peritoneum  is  not  incised,  but  is  made  bare  on  its  anterior  surface 
by  detaching  the  rectus  muscles  from  it.  The  lower  part  of  the  peritoneum  is  then 
divided  and  the  abdominal  cavity  opened.  The  stomach  is  then  sought.  Through 
the  stomach  and  the  undivided  peritoneum  in  the  upper  part  of  the  wound  a  suture 
is  passed.  In  Duret's  original  operation  the  suture  was  of  silk  and  was  continuous. 
The  suture  is  passed  at  first  through  the  left  edge  of  the  parietal  incision  through 
fascia,  rectus  muscle,  and  peritoneum,  and  then  horizontally  through  the  serous 
and  muscular  coats  of  the  stomach  close  to  the  lesser  curvature.  The  needle  is 
now  passed  from  within  outward  through  the  uncut  peritoneum,  and  then  back  into 
the  abdomen  again  to  pick  up  the  stomach  as  before.  A  series  of  similar  loops  are 
made  in  the  suture  which  is  passed  along  the  greater  part  of  the  lesser  curvature  of 
the  stomach.  As  soon  as  the  stitch  is  tightened  the  stomach  is  strung  up  and  fixed. 
Duret's  first  case  did  well,  and  the  patient,  a  married  woman,  who  has  suffered 
severely  for  three  years  from  gastroptosis,  was  completely  relieved,  and  in  two  years 
had  gained  25  pounds  in  weight. 

Beyea's  operation  is,  in  my  judgment,  the  most  satisfactory  of  all  methods. 
Beyea^  gives  the  following  description  of  it : 

"An  incision  about  three  inches  in  length  was  made  through  the  linea  alba,  mid- 
way between  the  xiphoid  cartilage  and  umbilicus.  The  tissues  were  separated  in 
the  usual  manner  and  the  peritoneal  cavity  opened,  exposing  a  small  portion  of  the 
lesser  curvature  and  cardiac  end  of  the  stomach,  the  gastrohepatic  ligament  or 
omentum,  gastrophrenic  ligament,  and  the  lower  portion  of  the  left  lobe  of  the  liver. 
The  table  was  then  elevated  to  the  Trendelenburg  position  and  the  stomach  displaced 
still  further  downward  and  out  of  the  wound  by  means  of  gauze  sponges.     This 

^  Beyea,  Henry  D.:  "The  Elevation  of  the  Stomach  in  Gastroptosis  by  the  Surgical  Plication 
of  the  Gastrohepatic  and  Gastrophrenic  Ligaments:  An  Original  Operation,"  Phila.  Med.  Jour., 
1903,  i,  257. 


372 


OPERATIONS    UPON   THE   STOMACH. 


procedure  caused  the  gastrohepatic  and  gastrophrenic  ligaments  to  be  sUghtly 
stretched  and  separated  from  the  underlying  structures,  which  permitted  an  ac- 
curate determination  of  the  length  of  these  Hgaments  and  very  much  facilitated 
operative  manipulations.  The  gastrophrenic  ligament  was  seen  well  developed, 
and  evidently  formed  a  strong  support  to  the  cardiac  end  of  the  stomach.  The 
joining  portion  of  the  gastrohepatic  ligament  was  composed  of  thin,  delicate  peri- 
toneum, increasing  in  thickness  and  strength  toward  the  right  or  pyloric  end  of  the 
stomach.  Retractors  were  introduced  and  the  liver  held  aside  by  placing  a  gauze 
sponge  beneath  a  retractor.  Three  rows  of  interrupted  silk  sutures  were  then  intro- 
duced so  as  to  plicate  and  thus  shorten  the  gastrohepatic  and  gastrophrenic  ligaments 

in  the  following  manner. 
The  first  row,  beginning  in 
the  gastrophrenic  ligament, 
and  extending  across  the 
gastrohepatic  ligament  to  al- 
most opposite  the  pyloric 
orifice  and  hepaticoduodenal 
ligament,  w^as  introduced  so 
as  to  form  a  plication  in  the 
center  of  these  ligaments, 
and  included  from  above 
downward  or  vertically  about 
4  cm.  of  tissue  (row  No.  1). 
They  were  practically  mat- 
tress sutures,  including  suffi- 
cient of  the  delicate  tissue  (1 
cm.)  to  insure  against  their 
tearing  out.  Five  sutures, 
about  one  inch  apart,  were 
introduced  from  right  to  left 
and  caught  in  hemostatic 
forceps.  The  next  row  (row 
No.  2)  of  sutures  was  intro- 
duced in  the  same  manner, 
but  2.5  cm.  above  and  below  the  first  two.  Then  a  third  row  (row  No.  3)  was 
introduced  just  above  the  gastric  vessels  and  a  short  distance  below  the  diaphragm 
and  liver.  The  suturing  was  strictly  confined  to  the  normal  Hgamentary  supports, 
and  the  distance  between  the  rows  from  left  to  right  was  increased  with  the 
length  of  the  ligaments,  being  greater  toward  the  right.  The  gauze  sponges  were 
then  removed,  and  the  first,  the  second,  and  finally  the  third  row  of  sutures  were 
secured,  the  stomach,  particularly  the  pyloric  end,  being  elevated  to  a  little  above 
the  normal  position." 

The  sutures  were  of  silk.     Four  successful  cases  are  recorded.     A  similar  opera* 


Fig.  595. — Beyea's  Method  of  Gastropexy. 


GASTROPEXY. 


373 


tion  has  been  performed  by  Bier.  In  a  recent  letter  Beyea  kindly  informs  me 
that  he  has  operated  in  eight  cases,  with  marked  benefit  in  all.  The  first  case  re- 
mains well  after  eight  years.  I  have  only  once  performed  the  operation,  and  the 
result  has  been  very  good. 

The  advantage  of  the  operation  just  described  is  that  it  does  not  fix  the  stom- 
ach to  the  anterior  abdominal  wall,  and  therefore  does  not  interfere  with  the  proper 
mobility  of  the  organ. 

Coffey's  Method. — R.  C.  Coffey^  describes  a  method  of  "suspending  the  stom- 
ach in  a  hammock  made  of  the  great  omentum."  When  the  abdomen  is  opened 
the  stomach  is  freed  from  adhesions  and  pushed  gently  upward  into  its  normal  posi- 
tion. A  series  of  chromicized  catgut  sutures  are  then  passed  transversely  across 
the  abdomen,  picking 
up  on  the  one  side  the 
great  omentum  one 
inch  below  the  stom- 
ach and  on  the  other 
the  anterior  abdom- 
inal wall.  Coffey 
writes  as  follows: 

"As  to  the  technic, 
I  think  this  can  well 
be  varied  to  suit  the 
case  in  hand.  If  only 
the  stomach  is  dis- 
placed and  not  much 
dilated,  it  will  prob- 
ably be  sufficient  to 
put  one  row  of  sutures 
across,  about  an  inch 
below  the  attachment 
of  the  stomach.  If 
the  abdomen  is  much 

relaxed  and  the  colon  shows  a  decided  tendency  toward  prolapse  in  splanchno- 
ptosis, it  will  be  probably  well  to  put  two  rows  of  sutures  across,  penetrating  the 
entire  thickness  of  the  omentum  just  below  its  attachment  to  the  colon.  In  this 
way  such  a  broad  line  of  adhesion  will  be  constructed  that  it  will  practically  be 
impossible  for  the  organs  to  become  prolapsed. 

"In  my  first  case  I  placed  three  interrupted  chromicized  catgut  sutures,  covering 
a  space  of  about  2  inches,  near  the  center  of  that  portion  of  the  omentum  attached 
to  the  dilated  portion  of  the  stomach.  In  my  second  case  I  used  eight  chromicized 
catgut  sutures,  covering  a  space  a  little  more  than  6  inches.     In  case  of  a  very  much 

1  Coffey,  R.  C:  "Gastroptosis:  a  Method  of  Suspending  the  Stomach  in  a  Hammock  Made 
of  the  Great  Omentum,"  Phila.  Med.  Jour.,  1902,  x,  506. 


li. 


596. — Beyea's  Method  op  Gastropexy. 


374  PYLOROPLASTY. 

dilated  stomach  I  would  suggest  extending  the  suture  still  farther,  taking  in  8  or  10 
inches  across  the  omentum.  The  stitches  have  been  passed  about  2^  inches  above 
the  umbilicus  and  have  been  passed  from  a  large  longitudinal  incision,  as  shown  in 
the  cuts. " 

I  have  once  adopted  this  method  and  found  it  most  satisfactory. 

Rovsing's  Operation.^ — In  this  operation  three  stout  sutures  of  silk  are  passed 
transversely  through  the  stomach,  picking  up  only  the  inner  coats.  At  each  end  the 
silk  is  tied  over  a  glass  rod,  after  being  passed  through  all  the  layers  of  the  abdom- 
inal wall.  The  stitches  are  removed  at  the  end  of  four  weeks,  when  the  stomach  is 
solidly  fixed  to  the  anterior  abdominal  wall. 


PYLOROPLASTY. 
By  J.  M.  T.  Finney,  M.D. 

Operations  that  have  to  do  with  the  enlarging  of  the  diameter  of  a  strictured 
pylorus  have  been  suggested  from  time  to  time  by  various  surgeons.  These  opera- 
tions differ  from  each  other  both  in  the  method  of  procedure  and  the  size  of  the 
new  pylorus. 

Heineke^  in  1886  first  described  a  method  for  enlarging  the  pylorus  by  means 
of  a  transverse  curved  incision  through  the  anterior  wall  of  the  pylorus,  subsequently 
converting  this  into  a  vertical  incision  and  uniting  the  edges  by  suture.  The  fol- 
lowing year  Mikulicz^  reported  independently  the  same  procedure,  which  has  since 
borne  their  names. 

Durante^  in  1894  reported  a  plastic  operation  upon  the  pylorus  by  means  of  a 
transverse  V-shaped  incision  in  the  anterior  wall.  The  Y  incision  is  converted  into 
a  V  by  suturing  the  apex  of  the  Y  to  its  base. 

Segale^  in  1900  suggested  a  crescent-shaped  incision  with  the  convexity  downward. 
The  edges  are  slid  upon  one  another  horizontally  and  sutured,  thus  giving  a  spiral 
effect  to  the  new  pylorus. 

The  author*^  in  1902  reported  a  method  which  made  use  of  a  horseshoe-shaped 
incision  through  the  pylorus,  extending  well  down  upon  each  side  through  the 
anterior  walls  of  the  duodenum  and  greater  curvature  of  the  stomach  respectively, 
which  are  approximated  and  sutured  much  as  in  a  lateral  anastomosis. 

*  Rovsing,  Thorkild:  "Ueber  Gastroptose  und  ihre  operative  Behandlung,"  Archiv.  f.  klin. 
Chir.,  1900,  Ix,  803. 

^Heineke:    "Operation  de  Pylorusstenose,"  Inaug.  Dissert.,  Furth,  1886. 

^Mikulicz,  J.  v.:  "Zur  operativen  Behandlung  des  Stenosirenden  Magenschwures,"  Arch, 
f.  klin.  Chir.,  1888,  xxxvii,  79-90;  Verhandl.  d.  deutsch.  Geselsch.  f.  Chir.  Berl.,  1887,  xvi,  pt. 
2,  337-348. 

*  Durante,  F.:  "Ueber  Pylorusverschluss  u.  dessen  Behandlung,"  Central,  f.  Chir.,  1894, 
xxi,  1077. 

^  Segale,  J.  B.:  "Precede  de  pyloroplastie  par  glissement."  XIII  Congres  Internat.  de  Med., 
1900,  X,  640. 

8  Finney,  J.  M.  T.:  "A  New  Method  of  Pyloroplasty,"  Bull.  Johns  Hopkins  Hosp.,  July,  1902. 
"Three  Years'  Experience  with  Pyloroplasty,"  Surg.  Gyn.  and  Obst.,  1906,  ii,  2,  163. 


PLYOROPLASTY.  375 

Narath^  in  1904  described  two  methods  of  pyloroplasty,  the  first  of  which  con- 
sisted of  the  reflection  downward  of  a  flap  taken  from  the  anterior  wall  of  the  pylorus, 
duodenum,  and  stomach  on  either  side.  The  edges  of  the  incision  are  then  sutured 
as  in  the  Heineke-Mikulicz  operation.  This  procedure  is  simply  an  exaggeration 
of  that  operation.  His  second  method  is  practically  the  same  as  that  described  two 
years  previously  by  me,  differing  only  in  extent. 

Various  methods  of  gastroduodenostomy  have  been  described  by  Jaboulay,^ 
Henle,^  Villard,*  Kocher^  and  others,  but  since  they  do  not  include  the  pylorus, 
they  will  not  be  considered. 

The  name  "pyloroplasty"  has  been  retained  in  spite  of  certain  objections  that 
have  been  urged  against  the  earlier  procedures,  because  while  involving  an  incision 
through  the  walls  of  both  the  stomach  and  duodenum,  this  operation  concerns 
essentially  the  pylorus,  and  is  in  reality  an  enlargement  of  its  diameter,  necessitating 
its  division  in  every  instance;  while  gastroduodenostomy  need  not  disturb  the 
pylorus  at  all.  Gastro-pyloro-duodenostomy  would  be  a  more  correct  term,  but 
is  objectionable  on  account  of  its  length. 

Of  the  various  methods  of  pyloroplasty  mentioned  above,  the  author's  operation, 
for  obvious  reasons,  is  the  operation  of  choice,  since  it  admits  of  an  opening  of  any 
desired  size. 

The  operation  is  described  as  follows : 

If  there  are  any  adhesions  present  binding  the  pylorus  to  the  neighboring  struc- 
tures, they  should  be  freed  as  thoroughly  as  possible;  also  the  pyloric  end  of  the 
stomach  and  first  portion  of  the  duodenum.  Upon  the  thoroughness  with  which 
the  pylorus,  lower  end  of  the  stomach,  and  upper  end  of  the  duodenum  are  freed, 
depends  in  a  large  measure  the  success  of  the  operation  and  the  ease  and  rapidity 
of  its  performance.  I  want  to  emphasize  this  as  one  of  the  most  important  points 
in  the  operation.  Occasionally  at  first  sight  this  may  seem  impossible,  but  with 
care  and  patience  it  is  usually  found  that  it  can  be  accomplished  with  comparative 
ease.  Kocher  also  lays  stress  upon  the  advantages  to  be  gained  from  this  "mo- 
bihzation  of  the  duodenum,"  as  he  calls  it. 

A  suture  to  be  used  as  a  retractor  is  taken  in  the  upper  wall  of  the  pylorus,  which 
is  then  retracted  upward  by  means  of  this  suture.  A  second  suture  is  then  placed 
in  the  anterior  wall  of  the  stomach,  and  a  third  in  the  anterior  wall  of  the  duodenum 
at  equidistant  points,  say  about  10  cm.  from  the  suture  just  described  in  the  pylorus. 
The  second  and  third  sutures  are  taken  as  near  the  opposing  free  borders  of  the 
stomach  and  duodenum  as  possible,  and  mark  the  lower  ends  of  the  gastric  and 
duodenal  incisions  respectively.     Traction  is  then  made  upward  on  the  pyloric 

iNarath,  A.:  "Zwei  Vorschlage  zu  Modification  der  Pyloroplasty."  Archiv.  f.  klin.  Chir., 
1904, Ixxiv,  992. 

2  Jaboulay,  Mathieu:    "De  la  gastroduodenostomie/'  Arch.  Prop,  de  Chir.,  1S92,  i,  ^.'^l. 

^Henle,  A.:    "Ein  Fall  von  Gastroduodenostomie,"  Central,  f.  Chir..  1898,  xxv,  753. 

^Villard:  "Gastro-duodenostomie  sous-pylorique."  Bull.  Soc.  de  Chir.  de  Lyon,  1900,  iii, 
95-100.     Lyon  med.,  1900,  xciii,  522. 

5  Kocher,  T.:  "Mobilisierung  des  Duodenum  u.  Gastro-duodenostomie,"  Centralb.  f.  Chir. 
Leipz.  1903,  xxx,  33-44. 


376 


PYLOROPLASTY. 


suture  and  downward  in  the  same  plane,  on  the  gastric  and  duodenal  sutures.     This 
keeps   the   stomach   and   duodenal  walls  elevated  and  taut,  and  al- 

lows the  placing  of  the  subsequent  \  sutures  with  greater  facility  than 

if    they    remained    retracted     and    \  I      relaxed.    The  peritoneal  surfaces 

of    the    duodenum     and    stomach,      \  |       along  its  greater  curvature,  are 


Fos'teri  o  r 
conti  nuous 
Suture, 


Traction,    sot. 
at  pylorus 


Fig.  597. — Showing  Traction  Stitches  in  Pylorus,  Stomach,  and  Duodenum.     Posterior  Line  of  Suture 

Nearly  Completed. 


then  sutured  together  as  far  posteriorly  as  possible.  For  this  row  the  continuous 
silk  suture  is  best.  After  the  posterior  line  of  sutures  has  been  placed  and  tied, 
an  anterior  row  of  mattress  sutures  is  taken,  which  are  not  tied,  but  left  long  in  the 
manner  indicated  in  the  accompanying  drawings  of  the  operation  (Figs.  598,  599). 


PLYOROPLASTY, 


377 


These  sutures,  after  they  have  been  placed,  are  drawn  aside,  thus  exposing  the 
Hne  of  incision. 

After  all  the  anterior  stitches  have  been  placed  and 
retracted,  the  incision  is  made  in  the  shape  of  a  horse- 
shoe. The  anterior  and  pos- 
terior lines  of  sutures  should 
be  placed  far  enough  apart 
to  give  ample  room  for  the 
incision.  Beginning  in  the 
gastric  wall,  the  incision  is 
carried  up  to  and  through 
the  pylorus  and  around  into 
the  duodenum.  Hemorrhage 
is  then  stopped.  Scar  tissue 
or  active  ulcers  present  in 
either  the  gastric  or  duodenal 
wall  may  be  excised  through 
this  incision.  Redundant 
mucous  membrane  may  also 
be  excised.  A  continuous 
catgut  suture  is  now  taken 
through  all  the  coats  of  the 
stomach  and  duodenum,  on 
the  posterior  side  of  the  in- 
cision, in  order  to  reinforce 
this  line  of  sutures.  The 
anterior  sutures  are  then 
straightened  out  and  tied, 
and  the  operation  is  com- 
pleted. The  mattress  su- 
tures may  be  reinforced  with 
as  many  Lembert  sutures  as 
may  be  thought  best.  All 
the  stitches  are  thus  placed 
and  the  posterior  row  tied 
before  the  bowel  is  opened, 
and  it  remains  open  just 
long  enough  to  control  the 
hemorrhage,   thus   giving  the  minimum    of   exposure   of   infected   surfaces. 

The  size  of  the  newly  formed  pyloric  opening  may  be  made  as  large  or  small  as 
desired.  In  my  cases  the  new  pylorus  has  averaged  10  cm.  in  diameter.  Unless  the 
stomach  is  very  much  dilated  or  has  descended  to  an  unusual  extent,  the  lower  limit 
of  the  new  pylorus  will  be  found  to  be  at  or  near  the  level  of  its  most  dependent  part. 


Fio  598. — Posterior  Continuous  Suture  Placed 
AND  Tied.  Ends  Left  Long  as  Retractors. 
Anterior  Row  of  Mattress  Sutures  Placed 
BUT  NOT  Tied. 


378 


PYLOROPLASTY. 


This  operation  has  been  modified  by  Gould  by  the  use  of  clamps,  and  it  is  so 
performed  by  most  operators  today,  but  this  is  a  matter  of  choice  on  the  part  of  the 
surgeon.  An  ob\dous  objection  to  the  use  of  clamps  would  be  the  inability  to 
explore  the  inside  of  the  stomach  througrh  the  incision.  His  modification  of  the 
operation  is  as  follows : 


Fig.  599. — Axterior  Mattress  Sutures  Retracted.    Ixcision  Completed 
Through  the  Anterior  Gastric  and  Duodenal  Walls. 


When  the  duodenum  is  sufficiently  freed  clamps  are  applied.  On  the  duodenum 
a  fold  of  bowel  about  two  and  one-half  inches  long  is  taken  up  longitudinally,  and 
the  clamps  pushed  up  until  the  inner  jaw  rests  against  the  pyloric  sphincter.  On 
the  stomach  the  clamp  is  placed  in  a  similar  manner,  the  point  of  the  inner  jaw 


PYLOROPLASTY 


379 


touching  that  of  the  duodenal  clamp  at  the  pylorus.  The  ends  of  the  clamps  are 
not  freed,  but  grasp  the  bowel  half  an  inch  below  the  free  edge.  This  places  the 
clamps  at  right  angles  to  the  blood-vessels  both  of  the  stomach  and  of  the  duodenum. 
When  the  handles  of  the  two  clamps  are  brought  together,  the  pyloric  angle  is  put 
on  the  stretch,  thus  controlling  hemorrhage  and  preventing  leakage  from  this  in- 


FiG.  600.— Anterior  Gastric  and  Duodenal  Walls  Retracted.  Showing  Buttonhole  Suture  of  Catgut 
Partly  Placed  in  the  Free  Borders  of  the  Posterior  Walls. 

accessible  point.  If  the  clamps  are  placed  in  the  manner  recommended  above, 
the  remainder  of  the  operation  will  practically  amount  to  a  repetition  of  the  gastro- 
enterostomy technic.  The  folds  are  fastened  together  as  they  lie  side  by  side,  by 
the  usual  outer  seromuscular  stitch.  This  stitch  starts  at  the  pyloric  angle,  to 
make  sure  that  this  point  is  placed  at  the  apex  of  the  tongue  to  be  cut  out  later. 


380 


PYLOROPLASTY. 


The  incisions  into  the  bowel  and  the  stomach  are  hke  those  of  gastro-enterostomy, 
except  that  they  are  joined  at  one  end,  an  addition  which  is  made  possible  by  the 
continuity  of  the  two  organs.  The  stomach  incision  is  carried  down  until  the 
mucous  membrane  pouches  between  the  cut  muscular  walls.  The  stomach  incision 
is  then  left  and  the  duodenum  opened  until  the  mucous  membrane  is  met  at  the 
pyloric  angle.  The  pouching  mucous  membrane  is  removed  from  the  stomach 
by  cutting  with  scissors  close  to  one      ^    muscular  edge,  returning  on  the  other 

side.  The  completed  incision 
leaves  a  tongue-like  process 
made  up  of  half  stomach  and 
half  intestinal  walls.  The  two 
edges  of  the  tongue  are  next 
sewed  together  with  a  con- 
tinuous through-and-through 
chromic  stitch  wliich  starts 
at  the  apex  of  the  tongue 
and  goes  across  the  cut  to  the 
base.  At  this  point  the  suture 
is  interrupted  with  a  tie,  after 
wliich  the  suture  is  continued 
around  over  the  front  and  tied 
at  the  pyloric  angle.  It  is 
necessary  to  loosen  the  clamps 
before  placing  the  last  few 
stitches  of  this  suture,  since 
this  area  is  under  too  great 
tension  to  allow  the  edges  to 
be  brought  together.  The 
clamps  are  finally  removed  al- 
tog^ether  and  the  suture  buried 
in  with  a  continuous  seromus- 
cular suture. 

As  compared  with  gastro- 
enterostomy, the  objections 
urged  against  this  operation 
are  its  greater  technical  difficulties,  especially  in  the  presence  of  adhesions  and 
dense  cicatricial  tissue  about  the  pylorus;  that  it  does  not  take  advantage  of  gravity 
by  making  the  new  outlet  of  the  stomach  at  its  lowest  point;  that  it  is  inapplicable 
in  the  presence  of  active  and  bleeding  ulcers.  These  objections  are  more  fanciful 
than  real,  since  the  operation  has  been  repeatedly  performed  under  these  conditions, 
with  most  satisfactory  results.  The  interesting  experimental  work  of  Cannon  and 
Blake^  supports  this  contention. 

1  Cannon,  W.  B.,  and  Blake,  J.  B.:  "Gastroenterostomy  and  Pylorosplasty,"  Ann.  of  Surg., 
1905,  xli,  686. 


Fig.  601. — Mattress  Sutures  PREviotrsLy  Placed  Now  Tied. 
Alternate  Lemberts  Placed  Between  the  Mattress 
Sutures. 


PYLOROPLASTY. 


381 


On  the  other  hand,  certain  disadvantages  which  have  been  observed  in  connec- 
tion with  gastro-enterostomy,^ — namely,  vicious  circle,  peptic  ulcer  of  the  jejunum, 
subsecjuent  closure  or  contraction  of  the  anastomotic  opening,  etc., — have  not  been 


Fig.  602. — Operation  Completed.     Showing   Relative  Sizes  of  Old  and  New  Pylorus. 


observed.     The  mortality  rate,  too,  is  slightly  in  favor  of  pyloroplasty  as  against 
gastro-enterostomy.     One  of  the  satisfactory  features  of  this  operation  is  the  almost 


382  PYLOROPLASTY. 

entire  absence  of  post-operative  nausea  and  vomiting,  due,  possibly,  to  the  di\dsion 
of  the  pylorus.  The  endeavor  has  been  made  to  determine  as  far  as  possible  the 
limitations  of  the  operation.  It  has  been  found  in  the  author's  experience,  based 
upon  fiftv  cases,  that  tliis  operation  offers  greater  advantages  in  pyloric  stenosis  of 
benign  origin  than  does  the  operation  of  gastro-enterostomy.  It  has  also  been  found 
to  be  just  as  efficacious  as  gastro-enterostomy  in  the  presence  of  an  active  or  bleeding 
ulcer.  The  one  contraindication  that  has  been  so  far  determined  is  atonic  dilata- 
tion of  the  stomach  in  nervous  patients,  particularly  when  associated  wdth  a  dilated 
duodenum.  For  this  particular  condition,  however,  I  am  not  famihar  with  any 
operative  procedure  which  offers  adequate  rehef. 


CHAPTER  XXXIV. 

INTESTINAL  SURGERY. 
By  John  B.  Murphy,  M.D. 

MALFORMATIONS  OF  INTESTINE. 

Congenital  occlusion  of  the  small  intestine,  while  rare  in  any  location,  is  most 
frequent  in  the  duodenum;  the  next  most  common  site  is  the  ileocecal  region.  It 
may  arise  from  several  causes,  the  most  important  of  which  are:  (a)  intrauterine 
peritonitis;  (h)  amniotic  bands;  (c)  ulceration;  (d)  persistence  of  the  vitelline  duct; 
(e)  pressure  from  tumors  outside  the  bowel;  (/)  embolism  of  the  superior  mesenteric 
artery;  (g)  volvulus;  and  (h)  inguinal  hernia,  etc.  An  apparently  very  potent  and 
not  rare  cause  is  disease  of  the  fetal  l)lood-vessels;  obliterated  vessels  supplying 
organs  cause  either  maldevelopment  or  even  their  total  disappearance. 

Cordes,^  who  collected  fifty-six  cases  of  congenital  occlusion  of  the  duodenum, 
in  addition  to  one  of  her  own,  found  the  constriction  more  frequent  in  the  neighbor- 
hood of  the  common  bile-duct — just  above  it  in  twenty  cases,  and  below  it  in  thirteen 
cases.  Total  occlusions  are  more  frequent  than  stenoses.  In  fourteen  cases  there 
was  vomiting  of  meconium;  in  twenty-one  the  stools  contained  meconium  and 
one  was  intermixed  with  blood.  The  length  of  life  varied  from  thirty  hours  to  nine 
days  in  total  atresia,  and  from  thirty  hours  to  six  months  in  stenoses.  Herz^  regards 
occlusion  above  the  papilla  of  the  bile-duct  as  scarcely  distinguishable  from  pj'loric 
stenosis,  as  there  is  enormous  distention  of  duodenum  and  pylorus  (Fig.  603). 
When  the  stenosis  is  below,  the  differential  symptom  of  greatest  significance  is  the 
presence  of  bile  in  the  stomach,  which  in  some  cases  is  dilated.  The  stomach, 
whether  dilated  or  not,  always  contains  fluid  mixed  with  bile.  The  symptoms  are 
those  of  obstruction — persistent  vomiting,  obstinate  constipation,  and  icterus. 

Treatment. — When  the  occlusion  is  above  the  papilla,  a  posterior  gastro-enter- 
ostomy  by  suture  is  the  only  operation  indicated.  W'hen  it  is  below  the  papilla,  a 
duodenojejunostomy  lateralis  can  readily  be  performed,  as  the  duodenum  is  dilated 
to  a  great  degree  and  presents  a  large  serous  surface  to  which  a  side-to-side  attach- 
ment to  the  jejunum  can  be  readily  made.  After  passing  the  end  of  the  jejunum 
through  the  mesocolon  to  the  anterior  surface  of  the  duodenum,  a  lateral  union  can 
be  established  with  a  double  row  of  sutures.  The  end  of  the  jejunum  can  be  closed 
by  inversion.  The  same  operation  is  applicable  in  occlusions  at  the  duodenojejunal 
junction;  they  are  less  common  in  the  jejunum  itself  than  in  the  ileum. 

Occlusions  of  the  ileum  are   met  with,  as  a  rule,  in   the  vicinity  of   the  junc- 

'  Cordes,  L.:  "Congenital  Occlusion  of  the  Duodenum,"  Archiv.  Paediat.,  1901,  xviii,  401. 
'  Herz,  Hans:    "Die  Storungen  des  Verdauungs-Apparates,"  Berlin,  1898. 

383 


384  INTESTINAL   SURGERY. 

tion  of  the  vitelline  duct  attachment  (about  33  inches  above  the  ileocecal  valve). 


Fig.  603. — Stricture  of  Duodenum  (Cordes). 

A,   Stomach;   B,  pylorus;   C,  dilated  duodenum;   D,  constriction   of  stenosis  just  above 

papilla;  E,  papilla;  F,  jejunum. 

They  have  varying  degrees  of  closure  (see  Figs.   604-606)  and 
there  may  be  a  complete  separation  of  the  distal  from  the  proximal 
end  (Fig.  605).     In  "septate"  ileum  there  is  a  diaphragm  com- 
posed of   mucosa  and  circular  muscular  fibers  stretched  across  the  lumen.     The 

bowel  outside  may  be  perfectly  normal,  or  show  a  slight 


Fig.  604. — Persistent    Vitello- 
intestinal      duct         with 
Valve  (Bland-Sutton), 
a,  The  patent  vitello-intestinal 
duct;    6,  diaphragm;    c,  proximal 
end;    d,  distal  end;    e,  perforation 
in  diaphragm;     /,  patent  vitello- 
intestinal  duct. 


Fig.    605. — Imperforate    Ileum 

(after  Bland-Sutton). 

P,    Proximal;    D,    distal    end    of 

ileum. 


Fig.  606. — Congenital  Constriction 
OF  Ileum;  Small  Tube-like 
Connection.     Permeable. 

a,  Proximal  end;  6,  distal  end;  s,  sep- 
tum. 


constriction  corresponding  to  the  location  of  the  dia- 
phragm.    The   latter   may  be  imperforate  or  present 
an  aperture  of  varying  size.     A  man  of  sixty-two  years 
who  had  never  presented  symptoms  of  obstruction  and  whose  death  was  due  to 


MALFORMATIONS    OF   INTESTINE. 


385 


myocarditis,  was  found  to  have  a  diaphragm  36  inches  from  the  valve  (Hudson^). 
The  bowel  was  slightly  constricted  externally,  and  very  slightly  dilated  above  the 
partition,  normal  below,  showing  that  he  suffered  very  little  obstruction  from  the 
diaphragm.  Two  portions  of  bowel  may  be  connected 
by  a  narrow  pervious  portion  of  very  small  caliber,  often 
no  larger  than  a  crow-quill  (Fig.  608).  In  such  cases 
the  proximal  part  is  dilated  more  or  less  and  the  distal 
one  is  correspondingly  contracted. 

Finally,  the  bowel  may  end  in  a  blind  pouch,  sep- 
arated by  a  greater  .or  lesser  distance  from  the  blind  dis- 
tal segment.  Such  a  malformation  is,  of  course,  incom- 
patible with  life,  and  even  in  the  lesser  degrees  of  ob- 
struction death  usually  ensues  within  the  first  weeks. 
While  surgical  intervention  affords 
the  only  chance  of  relief,  the  results 
obtained  thus  far  have  been  most 
unsatisfactory  on  account  of  its 
tardy  application. 

Idiopathic  dilatation  of  the 
colon  {'megacolon ;  ectocolon  ; 
Hirschsprung's  disease)  is  a  rare 
affection.  DuvaP  was  able  to  collect 
but     forty-eight     cases;     Fenwick^ 

found  that  in  30,000  necropsies  at  the  London  Hospital  from 
1840  to  1900,  there  were  only  three  cases  of  ectasia.  Its  causation 
is  unknown.  It  is  a  disease  of  the  first  few  days  or  months  of  life, 
though  in  five  cases  the  symptoms  first  appeared  at  from  fifteen 
to  fifty  years  of  age.  It  is  much  more  common  in  males  (thirty- 
six  males,  nine  females) ;  the  character  of  the  food  seems  to  exert 
no  influence  whatever.  The  circumference  of  the  bowel  was  26  j 
inches  in  Banks's  case  and  23  inches  in  that  of  Walker.*  In  the 
one  of  Formad^  which  is  so  frequently  quoted  the  colon  contained 
47  pounds  of  fecal  matter.  In  thirteen  cases  (32.5  per  cent.)  the 
entire  intestinal  tract  was  dilated  and  in  twenty-seven  cases 
(67.5  per  cent.)  only  a  portion  was  ectasic.     In  the  latter  the  sigmoid  was  involved 


Fig.  607. — Septate  Ileum;  Small 
Opening;  Patent  Vitelline 
Duct  and  no  Change  in  Ex- 
ternal Appearance  of  In- 
testine. 

V,  Vitelline  duct;  d,  spiral 
diaphragm;  arrow  indicates  open- 
ing. 


Fig.  608. — Showing 
Septate  Ileum 
FROM  Congeni- 
tal Malforma- 
tion (Bland-Sut- 
ton). 

The  two  intestinal 
segments  communicate 
by  a  small  opening,  as 
indicated  by  the  arrow. 


^Hudson,  L.:     "On  Congenital   Abnormalities   of    the   Lower   Ileum,"    Trans.    Path.    Soc. 
London,  1889,  xl,  98. 

^  Duval,  P.:   "De  la  dilatation  dite  idiopathique  du  gros  intestin,"  Rev.  de  Chir.,  1903,  xxvii, 
332. 

3  Banks,  W.  M.:     "Enormously  Distended  and  Enlarged  Sigmoid  Flexure  of   the  Colon," 
Dublin  Jour.  Med.  Sci.,  1846,  i,  235. 

*  Walker,  J.:   "Congenital  Dilatation  and  Hypertrophy  of  the  Colon  Fatal  at  the  Age  of 
Eleven  Years,"  Brit.  Med.  Jour.,  1893,  ii,  230. 

5  Formad,  H.  F.:    "A  Case  of  Giant  Growth  of  the  Colon  Causing  Coprostasis,"  Univ.  Med. 
Mag.,  1892,  iv,  625. 
VOL.  II — 25 


386  INTESTINAL   SURGERY. 

in  twenty-one,  the  transverse  colon  in  ten,  and  the  descending  in  six.  The  rectum 
was  affected  in  three  cases  and  the  small  intestine  in  two  only.  The  dilatation  may 
occur  in  two  segments  some  distance  apart,  separated  by  an  intervening  segment  of 
normal  lumen.  The  mesocolon  is  always  thick  and  infiltrated,  the  appendices  epi- 
ploica?  large,  the  arteries  dilated,  and  the  mesenteric  nodes  often  hyperemic.  The 
wall  of  the  dilated  portion  is  generally  much  thickened ;  in  Mya's^  case  it  measured 
2.6  mm.,  instead  of  1.5  mm.,  as  normally.  In  one  of  the  author's  cases  it  measured 
Yq  inch.     The  mucosa  is  frequently  ulcerated. 

The  symptoms  are  simple,  and  can  be  summed  up  as  follows :  intractable  copro- 
stasis  and  abdominal  distention,  with  areas  of  percussion  flatness.  Other  mani- 
festations are  sequelae  of  these.  As  regards  the  former,  the  lapse  of  time  between 
bowel  movements  is  almost  incredible,  varying  from  five  or  six  days  to  as  many 
weeks.  In  Osier's^  case  a  child  of  seven  years  had  had  but  five  or  six  spontaneous 
evacuations  up  to  that  age.  Purgatives  and  enemas  have  no  effect;  even  colonic 
flushing  must  be  repeated  several  times  to  be  efficacious.  Flatus,  however,  escapes 
constantly.  The  abdominal  distention  is  enormous;  Osier's  patient  measured 
32  inches  in  circumference  at  the  navel,  and  Fitz's^  patient  28|  inches.  The  dis- 
tention is  greater  between  the  umbilicus  and  xiphoid  than  below  the  umbilicus. 

The  prognosis  is  grave;  in  forty-three  cases,  69  per  cent,  died;  eleven  from  ob- 
struction (three  acute,  eight  chronic).  Treatment  is  not  very  encouraging;  medical 
measures  are  of  little  use.  Ten  cases  were  operated  on  with  a  mortality  of  24.8 
per  cent,  (four  colostomies,  four  colopexies,  two  colectomies).  Intestinal  punc- 
ture has  been  resorted  to  four  times.  Ileostomy  or  cecostomy  in  complete  mega- 
colon is  the  only  operation  that  should  be  entertained.  It  can  be  performed  in 
less  than  five  minutes.  In  these  cases  the  bowel  should  be  united  to  the  skin  and 
a  large  opening  made,  as  the  bowel  has  lost  its  contractile  power,  and  the  latter  can 
only  be  restored  by  months  of  physiologic  drainage.  The  celluloid-hnen  (Pagen- 
stecher)  or  the  Turnbull  and  Wilson  black  Irish  linen  suture  is  preferable. 

Meckel's  diverticulum  {diverticulum  ilei),  found  in  about  2  per  cent,  of  all 
bodies  (more  frequent  in  the  male),  is  the  best  example  of  true  diverticulum.  It  is 
the  remains  of  the  omphalomesenteric  duct  of  the  fetus,  which  runs  from  the  primi- 
tive intestine  to  the  yolk-sac  and  disappears  later  on,  leaving  no  trace.  It  may 
remain  patulous  throughout,  or  only  at  the  intestinal  end  (Meckel's  diverticulum) 
or  at  the  umbilicus;  it  may  remain  patulous  in  the  middle  only;  lastly,  merely  the 
vessels  may  be  present. 

The  typical  specimen  of  this  anomaly  consists  of  a  blind  tube  the  same  diameter 
as  the  intestine,  given  oft'  at  right  angles  from  the  bowel,  within  a  meter  or  so  of  the 
ileocecal  valve.  Occasionally  it  comes  off  from  the  mesenteric  border,  in  which  case 
it  is  usually  provided  with  a  mesentery  of  its  own.     It  varies  in  length  from  a  teat- 

^  Mya,  G.:  "Due  Osservazioni  di  dilatazione  ed  ipertrofia  congenita  del  colon,"  Lo  Speri- 
mentale,  1894,  xlviii,  215. 

2  Osier,  W.:   "Notes  on  Tuberculosis  in  Children,"  Arch.  Pediat.,  1893,  x,  3. 

^  Fitz,  R.  H.:  "Persistent  Omphalo-mesenteric  Remains,"  Amer.  Jour.  Med.  Sci.,  1884, 
Ixxxviii,  30. 


MALFORMATIONS    OF   INTESTINE.  387 

like  projection  of  less  than  an  inch  to  one  of  8  or  more  inches.  The  end  may  be 
conical  or  T-shaped,  and  secondary  pouches  may  arise  from  the  diverticulum 
proper.     Occasionally  the  end  is  filiform  and  floats  among  the  intestinal  coils. 

The  principal  danger  from  the  presence  of  this  diverticulum  is  its  tendency  to 
give  rise  to  intestinal  obstruction,  about  5  or  6  per  cent,  of  all  cases  of  the  latter 
being  due  to  it.  If  it  is  very  long,  the  free  end  may  become  entangled  with  a  loop 
of  the  bowel,  forming  a  so-called  "knot."  The  diverticulum  in  rare  cases  may 
invaginate  into  the  bowel  alone  or  drag  the  bowel  with  it,  thus  obstructing  the 
latter.  It  may  enter  a  hernial  sac  (Littre's  hernia).  The  most  frequent  type  of 
obstruction,  however,  is  produced  by  fixation  of  the  distal  end  of  the  diverticulum 
to  the  wall  of  the  abdomen,  the  omentum,  or  the  intestine,  thus  forming  a  loop,  and 
in  this  loop  a  coil  of  intestine  or  omentum  becomes  strangulated;  this  is  much  more 
frequent  when  the  end  is  thread-like.  Of  sixty-three  cases  of  obstruction  due  to 
Meckel's  diverticulum,  the  end  was  free  in  fifteen  and  attached  in  forty-eight  (to 
mesentery,  twenty-three;  to  umbihcus,  fifteen;  not  detected,  three;  to  small 
intestine,  three;  mesorectum,  mesocolon,  omentum,  and  periappendicular  exudate, 
one  each — Halstead^). 

Oderfeld^  stated  that  the  presence  of  other  congenital  deformities  in  patients  with 
intestinal  obstruction — for  instance,  harehp  and  the  like — rendered  it  probable  that 
the  cause  of  the  obstruction  was  a  Meckel's  diverticulum.  This  was  first  pointed 
out  by  Matthew  Baillie  and  Meckel  many  years  ago,  and  does  not  seem  to  have 
proved  of  much  value  in  diagnosis.  The  symptoms  otherwise  are  the  same  as  in 
obstruction  from  other  causes.  As  the  diverticulum  contains  all  the  coats  of  the 
bowel  and  its  histologic  elements  in  its  make-up,  typhoid  and  other  ulcers  may  be 
found  in  it;  also  foreign  bodies. 

When  one  of  these  diverticula  is  encountered  during  an  operation  on  the  abdo- 
men for  other  causes,  it  should  be  excised,  and  the  opening  closed  with  a  purse- 
string  or,  if  large,  with  Lembert  sutures.  The  treatment  of  the  obstruction  will  be 
the  same  as  that  from  other  causes.  The  prognosis  is  serious;  of  thirty-two  lapar- 
otomies collected  by  Berard  and  Delore,^  death  ensued  in  twenty-three. 

Acquired  diverticula  (false  diverticula,  hernies  tunicaires),  unlike  the  form  just 
described,  are  not  made  up  of  all  the  coats  of  the  bowel,  the  serosa  and  the  mucosa 
escaping  through  a  hole  in  the  muscularis,  generally  on  the  side  of  the  mesentery 
near  the  exit  of  the  intestinal  veins.  They  are  most  frequent  in  the  large  intestine 
and  vary  in  number  from  a  few  up  to  four  hundred  (Hansemann). 

These  acquired  diverticula  are  a  common  appanage  of  old  age  with  its  accom- 
panying constipation,  and  have  been  considered  pathologic  curiosities.  I  have  had 
eight  cases  of  this  character:  in  three  of  these  the  diverticula,  located  in  the  sigmoid, 
suppurated  and  gave  rise  to  recurrent  attacks  of  peritonitis,  until  removed  by  ex- 

1  Halstead,  A.  E.:  "Intestinal  Obstruction  from  Meckel's  Diverticulum,"  Ann.  Surg..  1902, 
XXXV,  471 

-  Oderfeld:    (quoted)  in  London  Lancet,  1892,  i,  273 

^  Berard  and  Delore:  "Occlusion  intestinale  produite  par  le  Diverticule  de  Meckel,"  Lyon 
Medical,  1899,  xc,  129. 


INTESTINAL    SURGERY. 


section  of  that  segment  of  the  intestine.  In  three  others  drainage  was  instituted 
and  foreign  bodies  removed.  In  two  colostomy  diverted  the  fecal  current  from  the 
infected  zone  during  the  process  of  repair.  Occasionally  they  cause  fecal  ulcers  and 
even  perforation  and  peritonitis,  and  are  diagnosed  appendicitis.  In  a  case  re- 
cently reported  by  Gordinier  and  Sampson^  intestinal  obstruction  was  caused  by 
multiple  acquired  diverticula,  producing  obstruction  of  the  small  intestine. 

At  an  early  period  of  fetal  development 
the  primitive  large  bowel  crosses  in  front  of 
the  small  bowel  to  assume  the  position  found 
in  adult  life.  Occasionally  this  torsion  does 
not  take  place,  and  the  large  intestine  remains 
on  the  left  side  of  the  abdomen. 

If  the  mesentery  supporting  the  small  in- 
testine, ascending  and  transverse  colon  does 
not  become  adherent  to  the  posterior  wall  of 
the  abdomen,  we  will  have  the  condition 
known  as  persistent  common  mesentery. 
This  is  the  state  of  affairs  in  fetal  life  when 
all  these  segments  of  the  intestine  float  free 
in  the  abdomen  (Fig.  609).  A  common  mes- 
entery may  be  combined  with  absence  of  tor- 
sion of  the  primitive  bowel.  In  this  case  the 
small  intestine  is  found  to  the  right  of  the 
superior  mesenteric  artery  and  the  large  in- 
testine to  the  left.  The  practical  importance 
of  these  varieties  lies  in  the  fact  that  the 
cecum  and  appendix  will  be  on  the  left 
side. 

The  same  condition  of  affairs  obtains  in 
transposition  of  the  viscera.  Either  the 
thoracic  or  the  abdominal  viscera  alone  may 
be  transposed  or  both  together. 

When  the  mesocolon  is  over-developed — 
as  it  were — the  transverse  colon  is  thrown 
into  loops  or  bends,  which  invariably  point 
downward,  and  are  usually  angular,  V-  or 
W-shaped,  extending  into  the  pelvis,  where  it  may  become  adherent. 

The  hepatic  and  splenic  flexures  of  the  colon  may  be  lacking,  when  the  colon  as  a 
whole  is  shortened.  In  some  instances,  however,  though  these  flexures  are  wanting, 
the  colon  retains  its  customary  length  or  is  even  longer  than  usual. 

In  early  fetal  life  the  cecum  is  found  outside  the  abdomen ;  from  here  it  moves 
successively  to  the  umbilicus,  to  the  cardiac  end  of  the  stomach,  to  the  right  and  down 

^  Gordinier,  H.  C,  and  Sampson,  John  A.:  "  Diverticulitis  (not  Meckel's)  Causing  Intestinal 
Obstruction,"  Jour.  Am.  Med.  Assoc,  May  26,  1906,  xlvi,  1585. 


Fig.  609. — Persistent  Common  Mesentery, 
All  of  the  Intestines  Free  in  the 
Abdomen,  due  to  Failure  op  Em- 
bryonal Mesenteric  Revolution  (after 
Farabeuf). 

Coe,  Cecum;  M,  superior  mesenteric;  m,  infe- 
rior mesenteric  artery;  Pancr,  pancreas;  Splen, 
splenic  artery;   Hep,  hepatic  artery. 


INJURIES    TO    INTESTINES   DURING    OPERATIONS.  389 

into  the  iliac  region.  It  may  be  arrested  in  its  course  and  lie  close  under  the  liver, 
etc.,  or  it  may  drop  down  into  the  pelvis. 

The  sigmoid  loop  in  the  fetus  and  young  child  is  much  larger,  proportionately, 
than  in  the  adult.  This  fetal  condition  may  persist  through  life,  predisposing  to 
volvulus,  and  be  a  source  of  danger  in  this  part  of  the  bowel. 

Lastly,  reference  must  be  made  to  slits  or  openings  in  the  mesentery  and  omen- 
tum, a  fertile  source  of  intestinal  strangulation.  In  the  mesentery  these  are  found 
surrounded  by  the  terminal  branches  of  the  mesenteric  artery,  which  map  out  an 
area  absolutely  free  from  blood-vessels,  fat,  or  lymph-nodes.  In  some  cases  these 
holes  are  partly  or  wholly  covered  by  a  thin  membrane;  in  others  this  membrane 
is  cribriform  and  but  little  force  would  be  required  to  entangle  a  knuckle  of  bowel  in 
it;  in  still  others  there  is  a  round  or  oval  opening  with  smooth  edges,  an  inch  or  so 
in  diameter.  In  the  omentum,  loops  and  bands  are  found  sometimes  which  appear 
to  be  relics  of  old  attacks  of  peritonitis. 

INJURIES  TO  INTESTINES  DURING  OPERATIONS. 

The  intestines  must  be  carefully  protected  and  pushed  out  of  the  operating  field 
without  too  much  manipulation.  Xoble^  states  that  the  viscera  are  handled  much 
more  by  the  surgeons  in  Europe  than  by  the  surgeons  in  this  country,  and  that  this  is 
one  of  the  reasons  why  they  more  frequently  have  post-operative  complications. 
The  Trendelenburg  position,  associated  with  protection  of  the  intestines  by  a  large 
laparotomy  sponge  of  the  4-inch  roller  type,  will  prevent  unnecessary  and  injurious 
handling  of  the  intestines. 

Separation  of  Intestinal  Adhesions  from  Infected  Cysts  or  Malignant 
Tumors. — This  variety  of  adhesion,  as  well  as  that  between  the  intestines  them- 
selves, is  very  often  the  cause  of  injury  to  the  intestines.  Sometimes  this  can  be 
avoided,  and  again  it  may  be  impossible.  In  case  of  adhesions  to  malignant  tumors, 
— for  instance,  carcinoma  of  the  body  of  the  uterus, — the  growth  is  not  only  adherent 
to  the  wall  of  the  intestine,  but  has  infiltrated  it.  In  such  cases  a  safe  separation 
cannot  be  made  and  should  not  be  attempted,  but  exsection  performed  in  its  stead. 
In  removing  cysts  of  the  ovary  or  of  the  broad  ligament  adherent  to  the  intestines, 
injury  may  occur  either  in  the  form  of  perforation,  transfixion,  or  simple  abrasion, 
which  latter  will  form  an  organic  adhesion.  Other  injuries  occur  during  curettage 
of  the  uterus  in  the  hands  of  the  inexperienced.  The  literature  is  full  of  cases  of 
perforation  of  the  uterus  by  a  sharp  curet  with  subsequent  prolapse  of  the  coils  of 
intestine  through  the  perforation. 

I  have  recently  operated  on  a  case  in  which  the  uterus  had  been  perforated  during 

a  curetment.     The  operator  did  not  recognize  the  fact  for  three  days,  at  which  time 

he  found  a  coil  of  bowel  in  the  vagina.     He  at  first  supposed  it  was  the  funis,  and 

exerting  traction  upon  it  detached  18  inches  of  the  large  intestine  from  its  mesentery; 

recognizing  it  as  intestine,  he  replaced  it  all  within  the  vagina  and  transported  the 

1  Noble,  Charles  P.:  "  The  Present  Status  of  Gynecology  in  Europe,"  Amer.  Med.,  Oct.  19, 
1901,  p.  601. 


390  INTESTINAL   SURGERY. 

patient  to  the  hospital;  on  admission  the  temperature  was  105°.  I  made  an  im- 
mediate section  and  excised  18  inches  of  large  intestine,  made  a  side-to-side  an- 
astomosis with  the  button,  uniting  the  colon  with  the  very  short  stump  of  the  rectum; 
the  ends  were  closed  by  inversion  with  Pagenstecher  linen  Lembert  sutures.  The 
patient  recovered. 

Statistics  in  regard  to  injuries  of  the  intestine  during  operation  are  few  in  number. 
Blau  compiled  a  series  covering  cases  in  Chrobak's  clinic  from  1890  to  1900.  In 
2193  cases  the  abdominal  viscera  were  injured  forty-five  times  during  operation, 
the  uterus  fifteen  times,  the  bladder  tAventy-one  times,  and  the  intestine  fourteen 
times.  The  intestines  were  injured  seven  times  in  laparotomies  and  seven  times  in 
vaginal  operations.  Of  these  fourteen  cases,  eleven  ended  fatally  and  three  had 
intestinal  fistulse;   two  of  the  latter  healed  spontaneously. 

As  Blau  points  out,  the  intestines  are  injured  most  frequently  when  they  are 
adherent  to  the  adnexa.  There  may  be  primary  perforation  caused  by  the  finger  or 
instruments,  or  a  secondary  sloughing  from  the  trauma  inflicted  during  the  separa- 
tion of  adhesions  from  the  wall  of  the  intestine  and  surrounding  tissues. 

The  Trendelenburg  position  with  its  advantageous  exposure  of  the  field  is 
materially  lessening  the  number  of  similar  occurrences;  careful  inspection  adds 
much  to  the  tactile  sense  in  locating  the  lines  of  agglutination  or  adhesion.  When 
the  intestines  and  ovaries  are  matted  together,  too  much  care  cannot  be  exercised 
in  avoiding  injury. 

Many  suggestions  have  been  made  from  time  to  time  as  to  the  best  means  of 
preventing  injuries  to  the  intestines,  and  they  will  be  referred  to  later  on.  Price^ 
observes  that  in  general  better  results  are  obtained  in  gynecologic  operations  when 
performed  in  the  morning.  Tait"  stated  that  his  mortality  was  but  3  per  cent,  when 
he  operated  in  the  morning  and  8  per  cent,  in  the  afternoon. 


ILEUS— INTESTINAL  OBSTRUCTION. 

The  subject  of  intestinal  obstruction  has  always  been  one  of  great  interest,  and 
will  continue  so  until  our  methods  and  results  in  diagnosis  are  greatly  advanced. 
Before  entering  into  the  details  of  the  subject,  let  us  make  a  mechanical  estimate  of 
the  intestinal  tract  from  the  pylorus  to  the  sphincter  ani.  It  is  a  long  muscular  tube 
of  varying  size  with  anatomic  constrictions  in  certain  positions,  either  from  (a)  a 
special  muscular  development  (sphincters),  (h)  from  abrupt  changes  in  the  course 
of  the  canal  (flexures),  or  (c)  from  gradual  diminution  in  the  size  of  the  canal,  as  of 
the  lower  end  of  the  ileum.  This  canal  has,  besides  its  physiologic  functions  of 
secreting,  absorbing,  and  excreting,  the  power  of  propelling  its  contents  by  its  own 
muscular  contraction.     It  can  readily  be  seen  that  a  fecal  stasis  could  be  produced : 

First,  by  the  absence  of  muscular  contraction — paralysis.     This  paralysis  may 

1  Price,  Joseph:  "  Analysis  of  Common  Causes  of  Death  following  Pelvic  and  Abdominal 
Operations,"  Amer.  Jour,  of  Obstet.,  1903,  xlviii,  628. 

2  Tait,  L.:  "Dis.  Women  and  Abd.  Surgery,"  vol.  i,  1889. 


ILEUS — INTESTINAL    OBSTRUCTION.  391 

be  due  to  a  spinal  lesion,  an  interruption  in  the  afferent  nerve,  or  there  mav  be 
a  local  paralysis,  as  from  infection  at  the  terminal  filaments. 

Second,  from  tonic  contraction,  as  from  mineral  poisoning  (lead),  and  from 
certain  ptomain  poisons,  as  tyrotoxicon. 

Third,  it  may  result  from  mechanical  causes,  as  constriction  in  the  lumen, 
flexion  at  a  sharp  angle,  occlusion  by  a  foreign  body,  as  a  gall-stone  or  neoplasm; 
compression  from  without,  twisting  on  itself — volvulus. 

With  this  short  consideration  of  the  mechanics  of  obstruction  we  will  take  up 
the  subject  of  ileus  in  general  clinically.  By  the  term  ileus  is  meant,  not  a  definite 
pathologic  entity,  but  a  syndrome  of  symptoms  produced  by  very  different  causes. 
The  symptoms  of  ileus  are  abdominal  pain,  inabihty  to  produce  bowel  movements 
(coprostasis),  nausea  or  vomiting,  and  meteorismus  (tympanites).  These  symptoms 
may  be  produced  by  adynamic,  dynamic,  and  mechanical  causes. 

The  most  common  symptom  is  the  coprostasis,  and  as  this  can  result  from  such 
varied  causes,  it  seems  to  me  that  the  best  method  of  diagnosis  will  be  by  exclusion, 
which  can  only  be  effected  by  keeping  all  of  the  conditions  and  etiologic  factors 
clearly  in  view.  While  mechanical  ileus  is  the  only  true  type  of  intestinal  obstruction, 
coprostasis,  the  essential  symptomatic  factor,  is  produced  by  all  of  the  etiologic 
factors  mentioned  in  the  following  table.  It  would  be  more  acceptable  probably, 
from  a  purely  scientific  standpoint,  to  separate  the  dynamic  and  the  adynamic 
varieties  from  the  mechanical,  but  a  bedside  experience  with  extensive  material  has 
convinced  us  that  the  following  classification  is  the  most  practical  from  a  clinical 
standpoint  and  is  the  most  easily  applied  to  the  individual  case.  We  therefore  ad- 
here to  the  term  ileus  as  indicative  of  fecal  stasis  and  symptoms  associated  with  it, 
and  include  under  it  mechanical  obstruction  of  the  intestine. 

Pathology. 

The  scheme  on  page  392  is  a  synopsis  of  the  varied  pathologic  conditions  which 
produce  the  symptomatic  syndrome  of  ileus. 

Adynamic  ileus  signifies  without  power,  or  paralytic  ileus.  It  presents  all  of 
the  symptoms  of  a  coprostasis  from  mechanical  obstruction,  while  in  reality  it  is  one 
from  deficient  muscular  contraction.  It  constitutes  70  per  cent,  of  all  cases  of  ileus; 
it  is  always  the  result  of  paralysis  of  a  larger  or  smaller  portion  of  the  intestine  from 
the  following  causes : 

1.  Paralysis  from  extensive  operations  on  the  mesentery,  disturbing  its  circula- 
tion and  motor  nerve-supply. 

2.  Paralysis  of  a  loop  returned  after  prolonged  strangulation,  particularly  from 
femoral  hernia. 

3.  Injuries  to  the  spinal  cord,  as  fractures,  bullet  wounds,  and  punctures. 

4.  Injury  to  the  afferent  nerve,  mediastinal  bullet  or  stab  wounds. 

5.  Reflex  paralysis,  as  that  produced  by  the  transit  of  gall-stones  in  the  ducts, 
renal  calculi,  strangulated  omentum,  compression  of  an  ovary,  or  torsion  of  a  tumor 
pedicle  to  a  degree  of  strangulation. 


392 


INTESTINAL   SLRGERY. 


Ileus  . 


Adynamic  Ileus 
(Paralytic),  Symp- 
tomatic Intestinal 
Obstruction 


SCHEME. 

1.  Operations  on  mesentery. 

2.  Prolonged    strangulation. 

3.  Spinal  paralysis  from  trauma,  etc. 

4.  Afferent  nerve  lesion. 


5.  Reflex. 


^   4 
5 

6 
1 


6.   Septic. 


Dynamic  Ileus  (Ex- 
cessive Muscular 
Action) 


Mechanical  Ileus, 
from  Intestinal 
Obstruction 


7.  Uremic. 

8.  Tabetic  crises. 

9.  Acute  pancreatic  fat  necrosis. 

Lead  poisoning,  chronic. 
Tyrotoxicon  poisoning. 

f  Inguinal. 
f  External    (her-   j    Femoral. 

nia) -j   Umbilical. 

Ventral. 
Lumbar. 


Strangulation. 


Strangulation  of  omentum. 

Hepatic  calculus,  colic. 

Renal  calculus. 

Ovarian  compression. 

Torsion   of  tumor   pedicles   to   degree  of 

strangulation. 
Diaphragmatic  pleurisy. 
Local  peritonitis. 

2.  General  peritonitis. 

3.  Embolism  (mesenteric). 

4.  Thrombophlebitis  (portal). 


.  Internal. 


Obturation. 


f  Peritoneal      and      subperi- 
toneal pockets. 
Diaphragmatic  hernia. 
j   Inguinal    hernia     (internal 
I        ring). 
Umbilical   hernia  (divertic- 
ular). 
Adhesive  bands. 
I   Volvulus. 
[  Intussusception. 

/  Internal. 
\  External. 
Cicatricial  contraction. 
Fecal  impaction. 
Foreign  bodies  (enterolith). 
[  Congenital  stenosis. 


Neoplasms . 


6.  Septic  paralysis  from  peritonitis,  cholecystitis,  salpingitis,  embolism  of  mesen- 
teric artery,  appendicitis,  etc. 

About  90  per  cent,  of  the  cases  of  ileus  involve  the  small  and  10  per  cent,  the 
large  intestine;  about  70  per  cent,  occur  in  males. 

In  the  first  class  where  extensive  operations  have  been  performed  on  the  mesen- 
tery for  the  removal  of  tumors,  the  repair  of  lacerations,  etc.,  there  is  always  danger 
of  paralysis  and  gangrene  of  the  coil  as  a  result.  I  have  shown  by  experiments  that 
the  parallel  artery,  which  runs  in  the  mesentery  close  to  the  bowel  wall,  must  be 
given  the  greatest  consideration  in  operating  on  the  bowel  and  mesentery.  When 
it  is  injured,  as  by  a  bullet,  or  in  an  operation  for  the  removal  of  fibromata,  lipo- 
mata,  etc.,  resection  should  be  made  of  that  portion  of  the  intestine  from  which  this 
blood-supply  has  been  cut  off. 

Ileus  folloiving  the  return  of  a  bowel  that  has  been  strangulated  for  a  considerable 
time,  and  particularly  the  severe  strangulation  of  femoral  hernia,  is  due  to  thrombo- 


ILEUS — INTESTINAL    OBSTRUCTION. 


393 


sis  of  the  veins,  or  a  local  paresis  or  ischemia  from  the  occlusion  of  the  parallel  artery, 
and  not  infrequently  causes  a  fatal  termination  in  cases  where  appearances  promised 


Fig.  610. — Adyn.\mic  Ileus:  Thrombosis  of  Mesenteric  Artery  (Bloodgood). 
a,  Normal  area;  6,  thrombosed  area. 


a  restoration  of  circulation  and  function  of  the  bowel  when  returned.     This  form  of 
ileus  must  not  be  confounded,  however,  wuth  that  followino;  reduction  of  hernia  en 


394  INTESTINAL   SURGERY. 

bloc,  which  will  be  considered  later.  Necrosis  with  perforation  or  encapsulation  may- 
result. 

A  rare  cause  of  ileus  is  embolism  of  the  mesenteric  artery,  producing  an  ischemia, 
paralysis,  and  gangrene. 

Hemorrhage,  pathologic  lesions,  or  injuries  of  the  spinal  cord  produce  a  paralysis 
of  the  intestine,  fohowed  by  great  meteorismus,  which  may  continue  for  several  days 
after  the  injury.  It  is  one  of  the  most  unpleasant  complications  following  fractures 
of  the  spine.  The  abdomen  becomes  enormously  distended,  interferes  greatly  with 
respiration,  and  may  even  produce  prolapsus  recti. 

Injurij  to  the  afferent  nerve-supply,  as  a  blow  upon  the  epigastrium,  may  pro- 
duce a  paralysis  and  all  the  manifestations  of  obstruction;  a  bullet  wound  in  the 
mediastinum  may  have  the  same  effect,  as  is  illustrated  in  the  following  case,  which 
occurred  during  my  service  at  Cook  County  Hospital  in  the  spring  of  1890: 

A  police  officer  was  pursuing  a  burglar  upstairs,  when  the  latter  turned  and  fired 
downward.  The  bullet  passed  into  the  mediastinum  at  the  right  sternoclavicular 
junction.  There  was  no  evidence  of  injury  to  the  lung,  large  blood-vessels,  nor 
stomach,  but  the  patient  gradually  developed  the  symptoms  of  ileus;  pain  in  the 
abdomeil,  not  severe;  slight  tenderness,  persistent  vomiting;  enormous  distention 
of  the  abdomen ;  flatness  of  the  most  dependent  portion  of  the  abdomen  upon  change 
of  position;  complete  absence  of  peristalsis;  inability  to  induce  bowel  movement. 
These  symptoms  continued  for  seven  days;  patient's  pulse  was  then  140;  tempera- 
ture, 99°;  respiration,  46;  facial  expression  bad,  and  death  seemed  imminent. 
Diagnosis,  perforative  peritonitis,  through  the  diaphragm.  Laparotomy:  The  in- 
testines were  found  enormously  distended,  but  not  congested  in  the  least;  no  in- 
flammation at  any  place  in  the  peritoneum;  a  small  quantity  of  transuded  serous 
fluid  was  present  in  the  most  dependent  portion  of  the  cavity.  The  fluid  contents  of 
the  bowel  gravitated  with  alteration  of  position  and  explained  the  cause  of  the 
change  in  the  location  of  dullness  noticed  before  operation,  viz.,  that  dullness  was 
present  always  in  the  dependent  portion  of  the  abdomen,  but  the  operation  showed 
it  was  not  due  to  free  fluid  in  the  cavity,  but  to  fluid  that  gravitated  to  the  dependent 
portion  of  the  intestine  on  account  of  the  complete  paralysis.  The  stimulation  of  the 
operation  produced  an  active  peristalsis,  which  was  soon  followed  by  the  passage  of 
gas  and  feces;  vomiting  ceased,  pulse  improved,  and  the  patient  made  a  rapid  and 
uneventful  convalescence.  This  is  a  typical  case  of  ileus  from  afferent  nerve 
paralysis. 

Reflex  ileus  maybe  produced  by:  (a)  strangulation  of  omentum;  (b)  gall-stone 
obstruction  in  the  cystic  or  common  duct;  (c)  impaction  of  renal  calculus  in  ureter; 
(d)  compression  of  an  ovary;  (e)  diaphragmatic  pleuritis;  (/)  torsion  of  tumor 
pedicle  to  degree  of  strangulation  (Fig.  612). 

In  strangulated  omentum  the  symptoms  of  ileus  are  very  pronounced  and  con- 
tinue for  a  considerable  time.  The  differential  diagnosis  between  it  and  mechanical 
obstruction  of  the  intestine  is  based  on  the  presence  of  borborygmus  in  the  former 
and  its  absence  in  the  latter. 

Another  cause  of  reflex  ileus  which  has  been  recently  emphasized  is  torsion  of  the 
omentum  (Plate  V). 


PLATE  V. 


Torsion  of  the  Omentum  (Scudder). 


ILEUS — INTESTINAL    OBSTRUCTION. 


395 


X 


Oi'ctr-. 


Fig.  611. 


This  was  first  discovered  by  Oberst^  of  Volkmann's  clinic  in  1882,  and  some 

forty-four  have  been  recorded  in  the  intervening  period.     The  condition  is  much 

more  frequent  in  men  (75  per 

cent.),   the  ages    ranging  from  ^,^,^--?B;3s*35^5s?3E53a?'^-?sT^ 

nineteen  to  seventy-nine.     Her- 
nia coexisted  in  nearly  all  cases. 

The   femoral    variety    has   not 

been  met  with  so  far,   but  of 

nineteen  cases  a  right  inguinal 

hernia  was  present  in  thirteen. 

As  a  rule,  the  hernias  were  of 

long  standing,  some  congenital, 

and    in    others    from    eight    to 

thirty  years.     The  hernial  mass 

was  generally  reducible,  at  least 

up  to  the  onset  of  symptoms;  in 

one,  however,  it  had  been  irre- 
ducible for  twenty  years.     The 

size   of    the   hernial   protrusion 

seemed  to  have  been  of  no  sig- 
nificance.    Oberst  believed  the 

cause  in  his  case  was  violent 

taxis;  this  seemed  to  hold  good 

also  in   Hochenegg's^    case;   in 

four  it  was  thought  that  violent 

and   sudden    efforts   had    brought    on    the   condition. 

cause  could  not  be  determined. 

As  regards  the  'pathologic  anatomy,  a  hernial  sac  was  always  found  on  the  same 
side  as  the  omental  tumor.  In  four  the  sac  was  empty,  in 
thirteen  it  contained  the  lower  part  of  the  omentum,  and  in 
one  the  middle  part;  the  intestine  was  never  found  in  the 
sac.  The  part  of  the  omentum  within  the  sac,  while  never 
strangulated,  had  generally  undergone  the  changes  usually 
met  with  in  epiplocele  incarcerations.  Adhesions,  for  ex- 
ample, were  especially  noticeable,  varying  from  single  bands 
up  to  nearly  total  obliteration. 

Torsion  of  the  omentum  is  divided  by  Vignard  and  Gir- 

audeau"*  into  three  varieties :  Torsion  at  a  single  point,  at  two 

difl^erent  points,  and  complex  torsion.    The  first  is  by  far 

the  most  common  (thirteen  cases),  the  second  has  been 

seen  four  times,  and  complex  torsion  three  times. 

The  number  of  turns  varies  from  one  to 

several;  six  appears  to  be  the  maximum. 

'Oberst,  M,:  "Zur  Kasuistik  des  Bruch- 
schnittes  nebst  einigen  Bemerkungen  Uber  Netze- 
licklemmungen,"  Cent.  f.  Chir..  1882,  ix,  441. 

2  Hochenegg,   Julius:    "Ein  Fall   von   Ileus, 

bedingt  durch  eine  in  ihrem  Stiele  torquirte  Ovar- 

ialcy.ste,"  Wien.  klin.  Woch..  1888.  i,  Nr.  2.  29. 

^Vignard    et    Giraudeau:     "Torsion    intra- 

FiG.  612.— Torsion  OF  Accessory  Omentum.     One-       abdominale  du  grand  epiploon,"  Arch.  Provinc. 

HALF  Natural  Size  (Cullen's  case).  de  Chir.,  1903,  xii,  206. 


-Salpingitis  with  Twisted   Pedicle  Causing  Symp- 
toms OF  Ileus   (Seguin). 


In    the    rest   the    exciting 


Pedicl 


396  INTESTINAL    SrRGERY. 

The  diagnosis  is  very  difficult,  and  in  none  of  the  cases  was  it  made  previous  to 
operation.  In  five  it  was  mistaken  for  appendicitis.  The  symptoms  are  not  es- 
pecially striking  and  present  nothing  pathognomonic.  Pain  is  the  most  constant; 
it  is  abrupt,  acute,  and  agonizing,  and  so  marked  the  patients  are  forced  to  bed.  It 
is  generally  continuous,  though  in  a  few  it  was  intermittent,  and  in  one-half  it  was 
most  intense  at  the  apex  of  the  hernia.  Vomiting  was  present  in  one-third  of  the 
cases;  it  was  sometimes  greenish,  but  fecal  in  none.  There  was  no  temperature 
elevation,  which  should  have  differentiated  it  from  appendicitis  and  all  of  the 
septic  types  of  ileus.  Constipation  was  frecjuent;  complete  coprostasis  was  less 
common,  and  in  a  few,  the  occhision  not  being  complete,  there  was  passage  of  flatus. 
On  examination  the  abdomen  was  distended,  sensitive,  and  occasionally  presented 
a  small  amount  of  ascites.  Attention  is  soon  called  to  the  swelling  in  the  groin,  and 
many  observers  have  noted  the  presence  of  a  firm  mass  filling  the  inguinal  canal, 
acting  as  the  pedicle  of  the  tumor. 

In  the  collected  cases  recovery  was  the  rule.  One  patient  died  who  was  operated 
on  while  moribund;  one  from  delirium  tremens  and  two  from  bronchopneumonia. 

Prompt  operation  is,  of  course,  the  only  treatmeni,  and  if  we  cut  down  on  an 
apparently  strangulated  hernia  and  find  only  a  strand  of  omentum  in  the  inguinal 
canal,  the  portion  of  the  omentum  still  in  the  abdomen  should  be  carefully  examined 
to  be  sure  it  is  not  twisted. 

In  obstructions  to  the  cystic  or  common  duct  the  symptoms  of  ileus  are  also  pro- 
nounced and  continuous. 

Ileus  from  renal  calculus  is  of  shorter  duration  than  the  varieties  above  mentioned. 

Occasionally  an  ovary  is  compressed  between  the  bony  wall  of  the  pelvis  and  a 
fibroid  or  other  tumor,  producing  the  symptoms  of  ileus,  which  continue  with  greater 
or  lesser  severity  until  the  ovary  is  released.  Torsion  of  tumor  pedicles  may  occa- 
sion symptoms  resembling  ileus. 

Diaphragmatic  pleurisy  or  the  pleurisy  accompanying  lobar  pneimionia  is  fre- 
quently diagnosticated  as  intestinal  obstruction. 

Septic  or  infection  ileus  occurs  from:  (a)  peritonitis  general;  (h)  peritonitis  local. 
The  infection  of  the  peritoneum  may  occur  from  a  perforation,  through  impaired 
resistance  of  the  wall,  from  an  ulcer  in  the  appendix  or  intestine,  through  a  diseased 
tube  or  gall-bladder,  or  from  a  suppuration  contiguous  to  it.  As  a  result  of  this  in- 
fection, an  acute,  rapidly  destructive  type  may  develop  where  the  symptoms  of  ob- 
struction are  pronounced  at  the  onset  and  continue  until  a  few  hours  before  death, 
when  relaxation  takes  place,  and  there  are  frequent  fluid  bowel  discharges.  This  is 
characteristic  of  peritonitis  and  does  not  occur  in  mechanical  obstruction.  The 
infiltration  of  the  intestinal  wall  procluces  a  paralysis  of  peristalsis,  and  the  more 
virulent  the  poison,  the  more  complete  and  lasting  the  paralysis.  In  the  subacute 
and  circumscribed  inflammations  of  the  peritoneum  the  symptoms  of  ileus  are  less 
pronounced  and  pass  away  in  about  forty-eight  hours  after  the  onset  of  the  attack. 

Uremic  ileus  is  one  of  the  varied  forms  of  uremic  manifestations;  in  the  intestinal 
variety  we  have  symptoms  very  closely  resembling  those  of  mechanical  intestinal  ob- 
struction. The  physical  signs  of  mechanical  obstruction,  as  increased  peristalsis, 
tympanites,  and  circumscribed  areas  of  dullness,  are  absent,  while  the  vomiting  and 


ILEUS — INTESTINAL    OBSTRUCTION. 


397 


Fig.  613. — Loop  of  Intestine  Obstructed  by  Fibrous  Band. 

a,  Strangulated  loop;  b,  band  of  adhesion;   c,  proximal  end;  d, 

distal  end. 


coprostasis  are  persistent.  No  other  uremic  symptoms  may  be  present  to  suggest  the 
diagnosis,  but  an  examination  of  the  urine  demonstrates  organic  disease  of  the  kid- 
neys. It  must  be  remembered  that  intestinal  obstruction  can  occur  in  a  uremic  pa- 
tient and,  on  the  other  hand,  that 
a  small  percentage  of  albumin  is  ^ 

often  present  in  mechanical  ileus. 
Tabetic  crises  not  infrequently 
resemble  periodic  intestinal  ob- 
struction of  the  mechanical  type. 
The  pain,  nausea  and  vomiting, 
abdominal  distention,  and  copro- 
stasis are  present  and  often  con- 
tinue for  hours  and  days.  These 
cases  have  been  operated  upon  in- 
numerable times  for  mechanical 
obstruction,  as  also  for  gall- 
stones, renal  calculi,  etc.,  all  of  which  they  so  closely  mimic.  The  diagnosis  of  tabes 
can  usually  be  made  by  the  Argyll-Robertson  pupil,  the  Romberg  symptom  and  the 
absence  of  tendon  reflex,  etc.  It  must  be  borne  in  mind,  however,  that  true  intestinal 
obstruction  can  occur  in  a  tabetic,  and  a  most  painstaking  diagnosis  must  be  made 
to  avoid  error  on  either  side. 

Acute  Pancreatic  Fat  Necrosis;  Acute  Hemorrhagic  Pancreatitis. — Both  of  these 

have  the  characteristic  symptoms  of  ileus. 
The  primary  pain  is  more  intense  and  the 
collapse  more  severe  than  is  usually  found 
in  mechanical  ileus,  not  even  excepting  ex- 
tensive volvulus  or  severe  strangulations 
of  the  upper  jejunum  or  ileum.  The 
pressure  pain  is  greater  and  the  muscular 
resistance  in  the  upper  abdomen  much 
more  pronounced  than  in  the  mechanical 
type  of  ileus,  with  an  absence  of  temper- 
ature elevation  in  the  early  hours  of  the 
lesion  which  is  so  conspicuous  in  the  epi- 
gastric types  of  septic  ileus.  An  explora- 
tory incision  is  the  only  means  of  making 
the  differential  diagnosis.  The  swollen 
pancreas  and  the  gray,  yellow,  or  blood- 
colored  plaques  on  the  peritoneal  surfaces,  in  the  mesenteric  and  fatty  tissues,  are 
typical  and  diagnostic  of  the  pancreatic  lesion.  Careful  tamponing  with  incision  is 
the  treatment  of  these  conditions  when  they  are  discovered  in  the  exploratory  incision 
for  ileus.     Details  are  given  under  surgery  of  the  pancreas. 

Dynamic  or  Hyperdynamic  Ileus.— This  constitutes  2  per  cent,  of  the  cases 


Adh 


Fig.  614 


Obstruction  of  Intestine  by  Adher- 
ent Appendix  (after  Weir). 
a,  Appendix;  b,  distal  end;  c,  proximal  end. 


398 


INTESTINAL   SURGERY. 


of  ileus  and  is  produced  by  a  tonic  contraction  of  the  circular  muscular  fibers 
of  the  bowel.  This  contraction  may  continue  for  days.  It  may  be  caused  by 
poisoning  with  lead,  tyrotoxicon  from  milk,  cheese,  etc.  Borborygmus  is  feeble 
or  absent.  In  all  of  the  cases  of  adynamic  and  dynamic  ileus  no  opera- 
tive procedure  for  the 
_^ —        ^"^^ 


se    is    m 


di- 


ileus   jper 
cated. 

Ileus  from  tonic 
contraction  of  the  cir- 
cular muscular  fibers 
of  the  intestinal  wall 
has  a  mechanical  ob- 
struction with  all  of 
its  concomitant  symp- 
toms, lasting  many 
days.  The  writer  sec- 
tioned a  lead  colic  pa- 
tient after  seven  days 
of  coprostasis;  found 
a  coil  of  intestine  11 
inches  long  which  was 
hard  and  rope-like;  it 
rapidly  relaxed  after  a 
few  minutes'  exposure 
to  air  and  hot  applica- 
tions. 

Mechanical  Ileus 
or    Mechanical   Ob- 
struction.— This  rep- 
resents 28  per  cent,  of 
all  cases  of  ileus.     It 
is  subdivided  into:  (1) 
Strangulation    of    in- 
testine, internal   (Fig. 
615)  and  external  (her- 
nia); (2)  torsion  or  volvulus;  (3)  auto-invagination,  intussusception;   (4)  obtura- 
tion, internal  (neoplasms)   (enterolith)  and  external   (incarcerated   hernia)    tumor 
compression. 

The  internal  types  of  strangulation  are  very  numerous  and  most  difficult  of 
recognition.  They  are  produced  by  fibrous  bands,  adherent  appendix,  adherent 
intestinal  loops,  adherent  Meckel's  diverticulum,  slits  in  the  mesentery,  foramen  of 
Winslow,  congenital  subperitoneal  pockets  in  the  neighborhood  of  the  inguinal 
tract  and  femoral  opening,  retroperitoneal  fossae,  as  the  duodenojejunal,  external 


V. 


-^{ 


I 


^a-nd.  con.stTictlng' 
■'        rectum. 


Fig.  615. — Section  of  Sigmoid  and  Descending  Colon  Resected  for  Fecal 

Impaction. 
Measurement  11  inches  in  circumference,  17  inches  in  length.     From  child  five 

years  old. 


ILEUS — INTESTINAL    OBSTRUCTION. 


399 


sigmoid,  and  retrocecal.  These  subperitoneal  pockets  may  be  very  large,  and 
even  contain  the  entire  intestinal  tract  in  a  retroperitoneal  connective-tissue  pouch; 
a  greater  or  lesser  portion  of  straight  intestine  may  be  in  the  free  peritoneal 
cavity,  while  the  major  portion  may  be  behind  or  external  to  the  peritoneum. 
When  the  intestine  is  strangulated  in  one  of  the  pockets,  particularly  at  the 
duodenojejunal  fossa  or  in  the  retrocecal  cavity,  the  fixed  end  of  the  intestine  may 
be  mistaken  for  the  normal  intestinal  attachment  and  the  strangulation  overlooked. 
The  constricting  band  should  be  freed  and  the  intestine,  if  gangrenous,  withdrawn 
and  excised.  In  the  congenital  retroperitoneal  displacements  no  effort  should  be 
made  to  restore  the' intestine  to  the  peritoneal  cavity.  This  anomaly  occurs  usually 
as  a  great  surprise  to  the  operator,  and  unless  he  is  cautious  his  lack  of  information 
of  the  embryologic  relationship  may  lead 
to  danger  by  his  procedure. 

1.  By  stra7igulated  hernia  we  mean 
that  not  only  is  the  intestinal  tract  im- 
permeable to  its  contents,  but  that  the 
circulation  is  impeded  or  suppressed,  the 
nutrition  of  the  coil  is  shut  off,  and  its 
necrosis  is  imminent.  The  direct  mes- 
enteric vessels  are  the  first  to  yield  to  the 
pressure,  but  the  parallel  vessel  keeps  up 
the  blood-supply  for  a  long  time,  as  it  is  so 
thoroughly  protected  against  pressure  by 
its  position  and  its  encapsulation  with  fat. 

2.  Volvulus  or  torsion  of  the  intestine 
is  usually  secondary  to  some  intestinal 
adhesion  or  malformation,  except  when 
it  involves  the  sigmoid.  When  the  latter 
with  the  colon  is  included  in  the  volvulus, 
the  distention  is  often  enormous,  forming 
a  distinct  tumor. 

3.  Invagination  holds  a  middle  place  between  strangulation  and  obturation,  as 
well  for  the  severity  of  its  symptoms  as  the  tendency  to  local  necrosis  and  danger  to 
the  life  of  the  patient. 

4.  In  obturation  ileus  the  symptoms  come  on  more  slowly,  the  local  destruction 
is  more  gradual,  and  the  danger  to  life  is  more  distant,  depending  upon  the  degree 
of  obstruction  and  the  cause,  whether  it  be  simple  contraction  of  the  lumen  of  the 
bowel,  a  gradual  compression  of  its  caliber  by  an  occlusion  from  within,  an  obstruc- 
tion by  a  foreign  body,  as  a  gall-stone,  an  intestinal  fibroma  or  polypus,  a  gradual 
filling  and  compression  from  carcinoma  or  sharp  bending  of  the  canal.  Coprostasis 
of  many  days'  duration  in  these  cases  does  not  terminate  fatally. 

Neoplasms  are  not  infrequently  causes  of  intestinal  obstruction.  They  may  be 
divided  into  those  involvino-  the  intestinal  wall  and  those  external  to  and  com- 


FiG.  616. — Pahaduodenal  Fossa  or  Fossa  of  Land- 
ziHT  (after  Moynihan). 


400 


INTESTINAL   SURGERY. 


pressing  the  intestine;  each,  again,  may  be  subdivided  into  innocent  and  maUgnant. 
The  operative  treatment  is  mentioned  elsewhere.  The  most  common  type  of  non- 
mahgnant  obstruction  is  from  fibromata  or  polypi.  In  the  malignant  obstruction 
carcinoma  is  the  most  common;  it,  however,  rarely  occurs  in  the  small  intestine. 
Sarcoma  does  not  often  produce  a  diminution  of  the  lumen  of  the  intestine;  on  the 
contrary,  the  lumen  in  the  great  majority  of  cases  is  enlarged. 

Cicatricial  contraction  takes  place  most  frequently  at  the  site  of  an  ancient  ulcer. 

This,  however,  in  the  small 
intestine  is  not  at  all  neces- 
sary. We  have  annular  con- 
tractions from  cicatricial  de- 
posits in  the  fibrous  coat  of 
the  bowel  in  which  the 
mucosa  shows  no  evidence 
of  ever  having  been  in- 
volved, resembling  septate 
ileum.  The  etiology  of 
these  contractions  is  not 
known.  The  patients  often 
suffer  for  months  and  years 
from  periodic  obliterative 
ileus  before  they  come  to  the 
operating  table.  The  treat- 
ment is  excision  with  end- 
to-end  or  side-to-side  an- 
in  the  small 
preferably      the 


astomosis; 

intestine 

former. 

Foreign  Bodies — Entero- 
liths; Choleliths. — Entero- 
liths are  usually  formed  by 
undigested  particles  of 
food,  masses  of  hair,  etc. 
These  usually  form  in  the 
stomach  and  progress 
through  the  intestine,  sometimes  slowly  and  many  times  occupy  years  in  transit. 
I  recall  one  case  where  the  patient  suffered  from  periodic  obstructive  symptoms 
for  sixteen  years.  The  history  showed  that  the  primary  attack  shortly  followed 
the  swallowing  of  a  bolus  of  plum  pudding.  On  removing  the  mass  from  the 
intestines  by  enterotomy  in  an  acute  attack  it  was  clearly  demonstrated  that  it 
was  made  up  of  plum  pudding,  having  been  in  transit  in  the  intestine  for  sixteen 
years.  It  had  developed  many  diverticula  in  the  small  intestine,  and  it  was  only 
when  it  was  dislodged  from  one  of  these  pockets  that  it  gave  acute  symptoms.     In 


Fig.  617. — Treitz's  Case  of  Left  Duodenal  Hernia. 


ILEUS — INTESTINAL    OBSTRUCTION. 


401 


animals,  mainly  in  dogs,  hair  enteroliths  are  found.  There  is  no  pain  during  the 
time  these  masses  are  resting  in  the  diverticula,  but  when  they  move  forward  and 
dilate  a  new  area,  then  the  typical  obstructive  symptoms  are  produced.  Foreign 
bodies  are  best  removed  by  longitudinal  incision  in  the  convex  portion  of  the  bowel 
diametrically  opposite  the  mesenteric  attachment.  The  wound  should  be  closed  with 
a  Czerny-Lembert  suture. 

Fecal  inipactimi  occurs  in  the  large  intestine  only.  It  is  common  in  the  aged,  but 
is  not  infrequently  seen  in  middle  age.  In  children  it  occurs  in  association  with 
stenosis  of  the  rectum  or  sigmoid,  and  occasionally  fecal  accumulations  take  place  in 


Fig.  618. — Retroperitoneal  Hernia. 
The  large  intestine  is  pulled  up.     The  small  intestine  is  seen  to  be  enclosed  in  a  sac  behind  the  parietal  peri- 
toneum.    It  is  entirely  within  this  sac  save  the  terminal  portion  of  the  ileum  which  passes  out  over  the  stick.     The 
edges  of  the  paraduodenal  fossa  into  which  the  intestine  herniated  are  well  shown. 


the  balloon  enlargements  from  other  pathologic  conditions.  Recently  I  resected 
17  inches  of  the  sigmoid  and  descending  colon  for  impaction  in  a  child  five  years  of 
age.  A  year  preceding  the  fecal  accumulation  she  had  an  enormous  ballooning 
of  the  sigmoid  and  descending  colon  from  an  adhesive  band.  This  was  freed  bv 
operation  and  the  intestine  contracted  and  remained  so  for  a  year.  The  history  of 
fecal  retention  extended  over  a  period  of  sixty  days.  At  the  time  of  operation  the 
fecal  mass  was  11  inches  in  circumference  and  17  inches  in  length. 

Treatment. — Where  the  feces  cannot  be  molded  and  removed  through  an  anal 
dilatation  they  must  be  treated  by  section.     If  when  the  abdomen  is  opened  the 
fecal  mass  is  not  too  firm  to  permit  of  molding,  it  may  be  subdivided  into  small 
VOL.  ii~26 


402  INTESTINAL   SURGERY. 

round  masses  and  pushed  on  through  the  intestine  and  out  through  the  dilated  anus. 
If  it  is  situated  too  high  up  for  this  treatment  to  be  practicable,  a  longitudinal  enter- 
otomy  may  be  performed  and  the  fecal  mass  turned  out,  the  intestines  closed  with  a 
Czerny-Lembert  suture,  and  three  or  four  additional  rows  of  longitudinal  I^embert 
sutures  inserted,  enfolding  or  scrolling  the  colon  so  as  to  lessen  the  likelihood  of  sub- 
sequent dilatations.  If  the  ampulla  is  large,  and  particularly  in  young  people, 
excision  should  be  the  operation  of  election  with  end-to-side  or  side-to-side  approxi- 
mation either  by  suture  or  the  oblong  button. 

Diagnosis. 
Can  we  differentiate  with  any  degree  of  certainty  at  the  bedside  between  the 
various  forms  of  ileus  or  between  the  various  groups  ?  This  can  safely  be  answered 
in  the  affirmative.  When  we  consider  that  the  syndrome  or  symptoms  included  in 
the  term  ileus  occurs  under  so  many  distinct  and  varied  pathologic  conditions,  it  is 
easily  understood  why  the  results  in  practice  differ;  why  the  statistics  of  various 
men  differ;  why  one  class  of  doctors  finds  that  100  per  cent,  of  the  cases  of  ileus  not 
operated  die,  and  another  class  finds  that  34  per  cent,  of  them  recover  without 
operation.  The  reason  for  these  apparent  discrepancies  is  that  different  pathologic 
conditions  are  included  under  the  name  of  ileus  by  the  various  observers. 

History,  Etiology,  and  Clinical  Course. 

We  will  now  endeavor  to  draw  attention  to  the  history,  the  etiology,  and  the 
clinical  course  of  ileus  as  a  guide  to  the  treatment. 

The  history  will  assist  us  greatly,  indeed,  if  not  assure  us  of  a  diagnosis  of  in- 
testinal paralysis  resultant  from  operations  on  the  mesentery,  the  return  of  a  long 
strangulated  hernia,  injuries  to  the  spinal  cord,  injuries  to  the  afferent  nerve-supply, 
and  aids  us  somewhat  in  making  a  diagnosis  of  thrombosis  and  embohsm  of  the 
mesenteric  vessels  and  hernial  strangulation.  In  the  reflex  paralysis,  gall-stone 
colic  with  or  without  jaundice,  or  renal  coHc,  a  history  of  previous  attacks  aids  in  the 
diagnosis.  The  history  is  of  less  value  in  the  inflammatory  and  the  internal  mechan- 
ical varieties;  here  the  cfinical  course,  symptoms,  and  signs  will  have  to  be  relied 
upon. 

The  abdominal  pain  is  recognized  as  a  manifestation  of  irritation  of  the  terminal 
nerve  filaments  of  the  peritoneum  and  intestinal  wall,  and  will  vary  in  intensity, 
continuity,  and  locaHty,  depending  upon  the  lesion  present.  Pain  in  mechanical 
and  in  reflex  ileus  from  hepatic  and  renal  calculus  is  always  intermittent  or 
wavy.  Inability  to  produce  bowel  movement  has  already  been  explained  and 
may  be  due  to  many  causes,  which  will  be  given  in  detail  in  analyzing  the  different 
groups. 

Fecal  vomiting,  when  it  occurs,  always  comes  from  a  mechanical  obstruction  of 
the  intestines.  In  the  Hterature  on  the  subject  we  find  records  of  cases  where  formed 
feces  were  vomited.  The  accurateness  of  this  observation  I  question.  It  is  of  rare 
occurrence  to  find  vomitus  which  has  the  distinct  odor  of  feces.     It  is  an  odor 


ILEUS — INTESTINAL    OBSTRUCTION.  403 

different  from  the  fecal,  that  of  decomposition  of  intestinal  contents.  I  have  seen 
but  two  cases  in  an  extensive  experience  in  which  a  distinct  fecal  odor  was  present, 
and  both  were  obstructions  of  the  descending  colon.  Formed  feces  could  come  only 
from  the  large  intestines,  and  I  believe  this  has  never  occurred.  The  material  which 
has  been  considered  formed  feces  is  mostly  caseous,  curdled  milk,  which  has  re- 
ceived its  color  and  odor  in  the  stomach  from  the  regurgitated  contents  of  the  in- 
testine. One  should  never  wait  for  fecal  emesis  to  make  a  diagnosis.  The  vomit- 
ing in  mechanical  intestinal  obstruction  increases  in  frequency  with  increase  of  time. 
Reflex  vomiting  diminishes  with  time.  It  requires  as  much  knowledge,  experience, 
and  judgment  to  determine  when  not  to  operate  as  when  to  operate  in  ileus  cases,  as 
we  have  learned  that  72  per  cent,  of  all  cases  of  ileus  do  not  require  operations  for 
mechanical  obstruction. 

Meteorismus  occurs  in  three  places  in  the  intestine :  Above  the  seat  of  obstruction, 
in  the  strangulated  loop,  or  in  the  paralyzed  portion — the  latter  may  be  a  coil  or 
the  entire  intestinal  tract.  The  contents  of  the  distended  intestine  differ  materially 
in  the  three  different  conditions.  In  mechanical  occlusion  on  the  proximal  side  close 
to  the  obstruction  the  intestine  is  usually  full  of  liquid  feces,  principally  transudation 
from  the  mucosa.  With  strangulation  or  occlusion  of  a  coil  it  is  distended  about 
one-third  with  gas  and  two-thirds  with  liquid.  The  source  of  this  fluid  and  gas  I 
have  demonstrated  conclusively  to  be  transudation  and  decomposition.  This  gives 
circumscribed  areas  of  resonance  and  flatness  on  percussion. 

Of  the  constitutional  reactions,  one  deserving  particular  attention  is  the  excretion 
in  the  urine  of  phenol  and  indican.  These  are  the  products  of  absorption  of  decom- 
posed proteids  from  the  intestinal  tract.  The  indican  is  present  in  occlusions  of  the 
ileum  and  absent  in  obstructions  of  the  large  intestine. 

Next  in  importance  is  a  careful  physical  examination.  Inspection,  palpation, 
percussion,  and  auscultation  should  be  practised  systematically  in  every  case  of 
intestinal  obstruction,  as  each  has  a  very  positive  value  in  assisting  us  in  making  a 
diagnosis.  By  these  we  recognize  the  changes  in  form,  in  resistance,  position,  and 
movement  of  the  intestinal  coils. 

Symptoms. 

Adynamic  Ileus. — We  will  now  consider  the  symptoms  in  particular  forms  of 
ileus. 

Ileus  from  paralysis  following  extensive  operations  on  the  mesentery  can  be 
at  once  recognized  by  the  operator  and  managed  better  from  a  prophylactic  stand- 
point than  from  any  other;  that  is,  by  a  resection  of  the  portion  of  the  bowel  where 
the  circulation  has  been  compromised  at  the  time  of  the  primary  operation. 

Ileus  due  to  paralysis  of  long-standing  strangulation.  This  I  will  consider  when 
treating  of  hernia. 

Ileus  following  embolism  of  the  mesenteric  artery  has  no  pathognomonic  train  of 
symptoms  or  signs,  but  the  history  of  other  foci  of  sepsis  aids  very  nuich  in  leading 
to  a  diagnosis  of  this  rare  condition. 


404  INTESTINAL   SURGERY. 

Ileus  the  result  of  paralysis  of  the  intestine  from  injuries  to  the  spinal  cord  is 
readily  recognized. 

Injuries  to  the  afferent  nerve-supply  from  direct  contusion  or  from  bullet  or 
stab  wounds  produce  ileus  where  the  abdomen  has  not  been  involved  by  the  trau- 
matism directly;  this  variety  is  usually  accompanied  by  retention  of  urine,  while  in 
perforation  of  the  viscera  this  symptom  is  not  present. 

Reflex  ileus  from  renal  calculus  is  recognized  by  the  spasmodic  character  of  the 
pain,  its  location  in  the  loin  and  course  of  the  ureter,  its  intensity,  its  reflex  on  the 
bladder  and  testicle,  its  duration,  the  position  of  tenderness,  the  progressive  change 
of  its  location,  and  the  information  obtained  from  an  examination  of  the  urine. 
The  same  symptoms  are  of  value  in  recognizing  periodic  hydronephrosis. 

In  hepatic  calculus  there  is  greater  difficulty  in  making  a  differential  diagnosis. 
First,  -when  the  gall-stone  is  still  within  the  gall-bladder  the  pain  gradually  increases 
and  reaches  its  greatest  intensity  about  an  hour  after  the  onset.  It  continues  for  a 
few  hours  and  subsides  to  return  again  in  a  short  time.  There  is  no  borborygmus, 
no  elevation  of  temperature,  but  there  is  pronounced  local  hypersensitiveness. 
When  the  common  duct  is  obstructed  the  onset  is  more  sudden,  the  pain  more 
intense,  always  accompanied  by  bile  in  the  urine,  often  jaundice,  depending  upon 
the  duration  of  the  obstruction,  and  other  symptoms  well  recognized  and  familiar 
to  all. 

Another  variety  of  reflex  ileus  is  that  produced  by  compression  of  an  ovary  by 
fibroids.  It  may  be  recognized  by  the  history  of  the  case  and  the  location  of  the  pain, 
which  can  be  lessened  or  increased  by  certain  movements  of  the  fibroid,  and  fre- 
quently relieved  by  changing  the  fibroid  from  its  impacted  position.  There  is 
a  class  of  cases  in  which  the  manifestations  of  ileus  are  very  pronounced,  that 
due  to  the  mass  ligation  of  pedicles.  Since  the  practice  of  ligating  pedicles  en 
masse  has  ceased,  surgeons  are  ha^-ing  less  vomiting  after  operations,  and  fewer 
cases  of  post-operative  paralytic  ileus.  The  practice  of  ligating  a  large  pedicle  en 
masse,  formerly  in  vogue,  was  the  cause  of  many  of  the  reflex  symptoms  following 
operations  on  the  lower  abdomen.  If  a  large  pedicle  must  be  ligated,  it  should  first 
be  crushed  with  the  angiotribe  or  clamp  so  as  to  necrotize  the  tissue  at  the  point  of 
ligation ;  then  it  will  not  give  rise  to  reflexes. 

Diaphragmatic  pleurisy  or  pleuro-lobar  pneumonia  may  be  confounded  with 
intestinal  obstruction.  Error  is  more  common  in  children.  The  surgeon  is  called 
to  see  children  in  whom  there  is  enormous  distention  of  the  abdomen  with  pain, 
vomiting,  coprostasis.  There  is  absence  of  peristalsis,  and  the  same  intestinal 
inactivity  when  the  stethoscope  is  placed  on  the  abdomen  that  there  is  in  the  other 
types  of  paralytic  ileus.  But  there  is  always  present  in  this  class  of  cases  what  we 
never  find  in  primary  mechanical  obstruction  of  the  intestine — elevation  of  tempera- 
ture. 

Gastric  tetany,  with  or  without  hemorrhage  from  the  mucosa,  is  another  condition 
of  reflex  or  of  paralytic  ileus  that  is  mistaken  for  mechanical  obstruction.  The 
enormous  distention  of  the  stomach  to  two,  three,  or  four,  or  even  five  quarts  capacity 


ILEUS — INTESTINAL   OBSTRUCTION.  405 

immediately  after  operation  leads  to  the  belief  that  the  patient  has  obstruction  of  the 
bowel  below,  while  the  entire  condition  is  due  to  over-distention  of  the  stomach, 
notwithstanding  the  very  frequent  vomiting  of  small  quantities;  he  can  be  relieved 
of  the  vomiting,  distention,  and  distress,  only  by  passing  a  stomach-tube  and  with- 
drawing or  liberating  the  enormous  quantity  of  fluid  which  has  accumulated  in  the 
stomach.  This  condition  if  not  recognized  leads  to  a  fatal  termination.  The  same 
clinical  syndrome  is  occasionally  present  in  pyloric  stenosis  with  gastrectasia.  The 
stomach  becomes  so  dilated  that  it  may  reach  even  to  the  symphysis. 

Peritoneal  trauma  is  another — and  a  very  important — cause  of  paralytic  ileus. 
The  surgeon  who  produces  much  peritoneal  trauma  is  certain  to  have  excessive  mor- 
tality. The  peritoneum  is  a  sensitive  organ,  and  every  trauma  committed  in  the  oper- 
ation tends  to  produce  distention  and  paralysis  of  the  intestine  after  its  completion. 

Infection  Ileus. — Ileus  from  peritonitis  occurs  under  two  conditions,  namely, 
a  circumscribed  local  inflammation  and  a  general  peritoneal  infection.  In 
ileus  from  circumscribed  inflammation  we  have  the  symptoms  so  commonly 
observed  in  circumscribed  suppuration  at  the  seat  of  the  appendix.  The 
pain  occurs  suddenly  and  may  be  either  local,  referred,  or  general,  but  is  most 
severe  at  one  point.  The  nausea  and  vomiting  are  of  short  duration,  usually  not 
more  than  one  half  hour,  and  within  six  or  eight  hours  there  is  elevation  of  tem- 
perature to  100°  or  more,  and  not  infrequently  a  chill.  The  information  obtained 
from  the  pulse  is  of  little  significance.  Marked  resistance  of  the  abdominal  muscles 
and  tenderness  are  present  over  the  seat  of  inflammation.  The  tympanites  is 
limited.  The  apparent  induration  is  circumscribed.  The  deep  percussion  note  is 
resonant  in  the  early  stage;  the  piano  percussion  note  is  flat,  and  this  method  of  per- 
cussion I  consider  the  most  important  in  eliciting  dullness  when  small  inflammatory 
exudates  are  present.  Auscultation  shows  an  absence  of  peristalsis  over  the  region 
of  inflammation,  with  peristalsis  moderately  active  over  the  remaining  portion  of  the 
abdomen.  In  making  a  careful  examination  with  a  stethoscope  and  an  indelible 
pencil  it  is  interesting  to  note  how  accurately  the  area  of  adhesion  and  exudation  can 
be  outlined  by  the  absence  of  peristalsis  and  subsequently  proved  in  the  operation. 
The  symptoms  of  ileus  pass  ofl^  with  these  local  inflammations  in  from  twenty-four 
to  forty-eight  hours,  when  a  free  bowel  movement  can  be  produced  by  the  use  of 
cathartics.  These  same  symptoms,  only  less  pronounced,  occur  with  circumscribed 
adhesive  peritonitis  from  cholecystitis  and  tubal  infection,  and  in  each  case  can  be 
differentiated  by  its  location  and  history. 

Note  what  a  great  contrast  this  forms  to  the  ileus  of  general  peritonitis.  In 
this  variety  the  pain  is  intense  and  extends  all  over  the  abdomen;  the  nausea  and 
vomiting  are  persistent  for  days;  the  temperature  elevated  to  above  100°  except  in 
the  presence  of  collapse;  the  pulse  frequent,  small,  and  thready;  the  skin  cold; 
the  countenance  depressed;  anxious  expression;  enormous  and  uniform  meteoris- 
mus;  absence  of  abdominal  respiratory  movements;  knees  flexed.  On  palpation 
resistance  is  greatest  over  seat  of  origin;  muscles  are  firmly  contracted;  deep  per- 
cussion note  uniformly  resonant;   piano  percussion  note  dull  over  area  of  adhesion 


406  INTESTINAL   SURGERY. 

and  exudation.  There  is  complete  absence  of  peristalsis;  a  uniform  splashing  sound 
with  each  respiration,  caused  by  motion  of  fluid  in  bowel,  must  not  be  mistaken  for  it. 
In  such  a  condition  the  sound  is  uniform  with  every  respiration;  in  peristalsis  it 
varies  constantly.  It  is  impossible  to  induce  a  bowel  movement;  the  coprostasis  is  as 
complete  as  if  the  intestines  were  ligated,  and  remains  so  until  a  few  hours  before 
death,  when  relaxation  takes  place.  To  the  inexperienced  the  latter  is  considered  an 
indication  of  rehef  of  the  "obstruction,"  but  it  is  really  a  sign  of  impending  dissolu- 
tion. The  cause  of  the  ileus  in  these  cases  is  a  peripheral  paralysis.  In  septic  ileus 
there  is  always  a  primary  elevation  of  temperature;  in  mechanical  ileus  there  is  never 
a  primary  elevation  of  temperature;  in  both  there  may  be  a  hyperleukocystois  or  a 
hypoleukocytic  reaction  (leukopenia). 

The  symptoms  of  pain,  nausea,  and  vomiting  may  occur  just  the  same  in  the 
paralytic  as  in  the  mechanical  type.  Meteorism  is  as  pronounced  in  the  early  stage  of 
paralydc,  and  particularly  in  the  peritoneal  or  inflammatory  type,  as  in  mechanical 
ileus.  Coprostasis  is  the  same.  Borborygmus  is  always  absent  in  the  paralytic  type. 
It  is  one  of  the  most  pronounced  manifestations  of  mechanical  obstruction  of  the 
intestine,  and  a  stethoscopic  examination  in  a  case  of  mechanical  obstruction  gives 
more  information  than  one  of  the  chest  for  lesions  of  the  lung.  Absence  of  sounds 
means  absence  of  muscular  contraction.  Mechanical  ileus,  up  to  the  first,  second, 
third,  fourth,  or  fifth  day,  has  dechning  frequency  in  borborygmus,  but  this  can  be 
excited  at  any  time  by  massage  or  deep  percussion  of  the  abdomen. 

The  author  at  one  time  believed  that  hyperleukocytosis  was  of  great  value  in  the 
differential  diagnosis;  that  the  infective  type  would  show  a  high  and  the  mechanical 
type  a  low  leukocyte  count.  He  has  been  greatly  disappointed,  having  seen  a  36,000 
leukocyte  count  in  mechanical  ileus;  he  has  also  seen  a  7000  leukocyte  count  in  a  case 
of  sepdc  peritonids,  so  he  has  ceased  to  regard  it  as  other  than  of  corroborative  value. 

What  should  our  treatment  be  in  cases  of  ileus  from  circumscribed  and  general 
peritonids  ?  It  should  be  immediate  laparotomy.  By  this  means,  in  cases  of  cir- 
cumscribed peritonids,  the  cause  may  be  ehminated  and  the  inflammadon  prevented 
from  becoming  general;  not  that  all  cases  would  die  immediately  as  a  result  of  the 
disease,  but  that  the  immediate  and  remote  dangers  without  operation  are  very 
much  greater  than  with  operation.  In  general  peritonitis  the  danger  is  great  both 
with  and  without  operadon,  but  it  is  my  firm  conviction  that  an  early  operadon — that 
is,  an  operation  within  twelve  or  twenty-four  hours  after  the  onset  of  the  symptoms — 
will  save  pracdcally  all  of  the  cases.  An  operation  iri  the  late  stage,  when  the  patient 
has  cold  extremities,  capillary  cyanosis,  is  pulseless  at  the  wrist,  has  projectile  vomit- 
ing, and  dissolution  is  imminent,  should  be  discouraged,  as  it  does  not  benefit  the  patient 
and  brings  discredit  to  surgery. 

The  results  of  the  writer  in  forty-two  consecudve  cases  of  perforative  suppurative 
peritonids  (general)  show  what  can  be  accomphshed  by  operadon.  There  was 
only  one  death,  and  that  from  double  pneumonia  six  days  after  operation.  This 
includes  every  case  that  presented  itself  early  or  late.  The  greatest  stress  should 
be  laid  on  the  importance  of  early  operative  interference. 

Cases  of  adynamic  ileus  have  only  recently  been  brought  to  the  attention  of  the 


ILEUS — INTESTINAL    OBSTRUCTION.  407 

surgeon,  but  from  the  illustration  of  the  varieties  given  it  will  be  seen  that  there  is  a 
fertile  field  for  intelligent  surgical  interference,  based  on  accurate  diagnosis. 

Uremic  ileus  diagnosis  is  made  by  the  urinalysis  and  history. 

Tabes  can  be  differentiated  by  a  close  analysis  of  the  history,  but  numbers  of 
these  cases  have  been  operated  upon  for  ileus. 

Fat  necrosis  has  usually  profound  collapse,  intense  pain,  and  great  hypersensitive- 
ness  and  great  muscular  rigidity  in  the  epigastrium.  After  the  abdomen  is  opened 
the  gray  or  yellow  patches  on  the  peritoneum  and  intestine  indicate  the  diagnosis. 

Dynamic  Ileus. — Dynamic  ileus  or  ileus  from  spasmodic  contraction  of  the 
muscular  wall  occurs  first  from  ptomain  intoxication,  as  that  obtained  from  cheese, 
milk,  ice-cream,  oysters,  etc.,  and  second  from  chronic  lead  poisoning.  In  the 
former  the  pain  is  intense  and  often  relieved  by  pressure.  The  vomiting  is  incessant; 
tenderness  absent;  abdomen  retracted;  inability  to  move  the  bowels;  patient 
collapsed.  These  symptoms  may  continue  until  death,  which  occurs  from  toxemia. 
If  the  patient  survives  the  immediate  effect  of  the  poison  it  is  usually  followed  by 
severe  gastro-enteritis. 

In  making  a  diagnosis  of  lead  poisoning  we  have  to  assist  us  the  occupation 
of  the  patient,  the  history  of  previous  attacks,  the  blue  fine  of  the  gums,  etc.  But 
the  increased  peristalsis,  the  local  meteorismus,  the  distinct  localization  of  the  pain, 
make  it  difficult  to  exclude  mechanical  obstructions. 

Mechanical  Ileus. — In  the  diagnosis  of  internal  strangulation,  no  matter  from 
what  cause,  we  have  the  same  symptoms  as  in  strangulated  hernia,  but  the  physical 
signs  are  dift'erent.  The  symptoms  of  internal  strangulation  are  as  follows:  Pain  in 
the  abdomen  which  comes  on  suddenly,  gradually  increasing  in  intensity  for  the 
first  half  hour,  followed  by  nausea  and  vomiting,  and  inabiUty  to  produce  bowel 
movement.  If  the  strangulation  be  severe,  there  is  an  increase  in  the  frequency  of 
the  pulse  (but,  as  a  rule,  in  the  early  stage  the  pulse  is  not  accelerated),  absence  of 
temperature,  absence  of  tenderness.  As  the  case  advances,  if  the  strangulated  coil 
be  large,  it  can  be  recognized  through  a  moderately  thin  abdominal  wall  by  its  dis- 
tention; the  coil  of  the  intestine  leading  to  it  may  also  be  recognized  by  a  circum- 
scribed elevation  of  the  abdominal  wall.  In  twenty-four  hours  all  of  these  symptoms 
will  have  increased  in  severity.  The  distention  of  the  coil  is  greater,  the  abdomen 
is  more  tympanitic,  sensitiveness  at  the  seat  of  obstruction  is  now  manifest,  and  the 
increased  resistance  of  the  occluded  coil  may  be  felt.  If  the  coil  be  small,  the  increased 
resistance  of  the  intestine  on  the  proximal  side  of  the  occlusion  may  be  felt  and  a  cir- 
cumscribed dullness  may  be  outlined.  This  varies  with  position,  depending  upon 
the  portion  of  the  intestine  involved  in  the  strangulation,  as  shown  in  the  von  Zoege- 
Manteuffel^  plates.  Peristalsis  is  very  greatly  increased  and  is  most  pronounced  in 
the  neighborhood  of  the  obstruction.  The  increase  in  peristalsis  continues  until 
peritonitis  sets  in,  when  it  entirely  disappears.  If  the  strangulation  be  sufficient  to 
produce  gangrene,  the  depression  will  be  more  marked,  but  the  local  manifestations 

'  Von  Zoege-Manteuffel:  "Zur  Diagnose  und  Therapie  des  Ileus,"  Arch.  f.  klin.  Chirurgie, 
xli,  1891,  565. 


408 


INTESTINAL   SURGERY. 


unchanged.  Opiates  paralyze  peristalsis  for  hours,  and  therefore  should  never  be 
given  in  acute  intestinal  lesions,  as  they  obscure  the  symptoms  and  signs  of  the 
pathologic  process. 


Fig.  619. — Volvulus  of  the  Descending  Colon  (Bloodgood's  case). 
The  outlines  of  the  twist  are  only  schematic. 

A  case  of  strangulated  diaphragmatic  hernia  is  now  not  difficult  to  diagnose,  as 
the  fluoroscope  shows  the  altered  upper  surface  of  the  diaphragm.  Its  proximity 
to  the  center  or  lateral  surface  can  also  be  determined  in  this  way  to  guide  one  as  to 
whether  it  should  be  a  transpleural  or  a  transperitoneal  operation. 


ILEUS — INTESTINAL    OBSTRUCTION. 


409 


Volvulus  is  not  a  rare  form  of  internal  ileus.  By  volvulus  we  mean  a  twisting  of 
the  intestine  upon  itself  for  more  than  three-fifths  of  a  circle;  less  than  this  does  not 
produce  obstruction.  We  have  all  the  symptoms  of  ileus;  the  pain  is  mild;  the 
vomiting  is  persistent;  coprostasis;  absence  of  temperature.  In  the  early  stage  the 
patient  shows  very  little  depression;  pulse  negative.  As  soon  as  the  twisted  coil  be- 
comes distended  it  can  be  recognized  by  its  shape  through  a  moderately  thin  ab- 
dominal wall;  local  meteorismus;  increased  local  resistance;  great  increase  of 
peristalsis  until  peritonitis  supervenes.  The  distention  of  the  abdomen  in  volvulus 
of  the  colon  and  sigmoid  may  be  greater  than  that  of  a  nine  months'  pregnancy. 


Fig.  620. — Sausage-like  Shape  of  Intussuscipiens  with  Point  of  Entrance  of  Intussusceptum. 
a,   Intussuscipiens;   b,   intussusceptum;   c,  point  of  entrance. 

Frequent  in  the  benign  mechanical  obstructions  is  cicatricial  contraction  of  the 
intestine  itself.  In  these  cases  the  onset  is  gradual,  so  much  so  that  the  patient 
sufi'ers  from  intestinal  disturbance  a  long  time  before  the  occlusion  takes  place. 
This  occlusion  frequendy  manifests  itself  by  sudden  pain,  nausea,  vomiting,  no  ele- 
vation of  temperature,  no  change  in  pulse,  inability  to  produce  bowel  movement. 
The  stethoscope  locates  the  position  of  the  obstructed  coil. 

Invagmafion  (intussusception)  (Fig.  620)  occurs  more  frequently  in  children  than 
in  adults.  The  onset  is  sudden ;  the  patient  usually  gives  a  piercing  shriek  from  pain 
in  the  abdomen;  depression  produced  is  very  great;  the  pulse  increases  rapidly  m 
frequency;   the  vomiting  is  persistent;   the  eyes  sunken;   cold  perspiration.     These 


410 


INTESTINAL   SURGERY. 


-\  (Meckel) 


Iv 


2(PeyerJ 

(inner  apesfj 


"%— 3 


symptoms  continue  for  about  two  hours,  when  they  gradually  diminish.  The  vomit- 
ing persists,  but  is  less  severe.  After  twenty-four  hours  blood  may  be  detected  in  the 
stools.  A  distinct  oblong  tumor  may  be  found  in  the  right  hypochondriac  region 
just  below  the  margin  of  the  ribs;  no  bowel  movement  can  be  produced.  The 
invaginated  bowel  may  protrude  from  the  anus;  there  may  be  a  single,  double,  or  even 
triple  intussusception.    The  most  common  position  is  in  the  ileocecal  valve  (Fig.  621). 

When  the  obstruction  is  due  to  a  gall-stone  or 
foreign  body  in  the  intestine,  the  symptom  of  vomit- 
ing is  very  marked,  the  meteorismus  and  the  de- 
pression are  less,  as  the  foreign  body  constantly 
changes  its  position  and  advances  further  in  the 
intestinal  canal.  It  may  form  a  diverticulum  and 
remain  stationary  for  days  or  months.  Again,  it 
must  be  borne  in  mind  that  moving  bodies  and  not 
stationary  ones  give  colic. 

We  have  in  strangulated  hernia  the  same  symp- 
toms as  in  internal  strangulation,  and  in  addition 
thereto  we  have  a  history  of  hernia,  and  the  pres- 
ence of  an  irreducible  tumor.  The  peristalsis  is 
increased  and  there  is  an  absence  of  induration  in 
the  abdomen,  except  where  peritonitis  is  present; 
then  there  is  a  marked  induration  about  the  seat  of 
obstruction  and  an  absence  of  peristalsis  in  that 
region. 

The  characteristic  signs  of  infective  peritonitis 
following  strangulated  hernia  are,  in  addition  to 
the  usual  symptoms  of  obstruction,  elevation  of 
temperature,  absence  of  peristalsis  near  the  position 
of  obstruction,  and  induration. 

Strangulation  of  the  omentum-  produces  usu- 
ally the  same  symptoms  as  an  intestinal  ob- 
struction, which  may  continue  for  two  or  three 
days,  depending  upon  the  degree  of  strangula- 
tion, and  if  sufficient  to  produce  necrosis  the 
symptoms  continue  imtil  gangrene  is  complete. 
This  may  occur  without  producing  a  suppurative 
peritonitis  or  even  an  infection  of  the  sac,  and 
subsequent  absorption  may  take  place.  It  is  not  uncommon,  however,  to  have 
an  incarcerated  or  strangulated  omentum  suppurate,  in  which  case  it  should  not 
be  reduced,  but  excised.  The  same  principle  should  govern  its  non-operative 
reduction  that  governs  that  of  a  strangulated  intestinal  hernia,  that  is,  a  hernia  of 
more  than  thirty-six  hours'  duration;  in  neither  should  reduction  ever  be  attempted 
except  by  operation,  when  the  hernial  contents  can  be  inspected. 


Fig.  621. — Diagram  of  Triple  Intus- 
susception Originating  in  Mec- 
kel's Diverticulum  at  the  Ileo- 
cecal Valve  (Carwardine). 

1,  Meckel;  2,  (Peyer)  inner  apex;  3,  outer 
apex. 


ILEUS — INTESTINAL    OBSTRUCTION.  411 

Another  danger  following  reduction  of  hernia  is  that  it  may  be  returned  en  bloc, 
or  a  small  knuckle  may  be  allowed  to  remain  in  the  ring;  in  these  cases  the  symptoms 
of  obstruction  do  not  subside  after  the  reduction,  and  it  should  be  the  rule  that  in 
all  cases  of  reduced  hernia,  where  the  symptom  of  vomiting  continues  for  six  hours 
after  reduction,  a  laparotomy  should  be  performed. 

As  an  illustration  of  incomplete  reduction  the  following  is  a  most  instructive  case, 
referred  to  me  by  John  W.  Hanna,  of  Winfield,  Iowa. 

Patient  admitted  to  St.  Joseph's  Hospital  December  30, 1894.  Six  days  previous 
when  he  alighted  from  his  buggy  the  hernia  came  down.  It  was  more  painful  than 
usual;  it  was  reduced  a  short  time  after,  but  the  pain  continued  and  he  soon  began 
to  vomit.  When  seen  by  Hanna  five  days  after  the  accident  the  patient's 
abdomen  was  tympanitic,  the  vomiting  had  continued;  the  pain  was  slight,  and  in 
the  five  days  the  bowels  had  not  moved.  Examination  revealed  the  inguinal  canal 
apparently  free.  The  patient  presented  the  same  symptoms  when  he  came  under 
my  observation  in  the  hospital,  except  that  a  small  hard  nodule  could  be  detected  on 
the  inner  side  of  the  right  inguinal  ring.  The  finger  could  pass  freely  into  the  canal 
without  obstruction.  The  nodule  was  sensitive  to  pressure  and  very  hard.  The 
scrotum  was  full  of  fluid,  which  the  patient  believed  was  from  an  old  hydrocele. 

Operation:  Hernial  sac  opened,  found  empty.  Incision  extended  up  into  ab- 
domen; just  below  the  outer  pillar  at  the  point  of  induration  was  found  a  knuckle 
of  intestine  passing  from  the  hernial  sac  through  a  very  narrow  opening  into  the 
hydrocele  sac.  The  abdomen  contained  a  considerable  quantity  of  serous  fluid. 
Before  the  hydrocele  sac  was  opened  the  field  was  well  packed  with  gauze  and  pre- 
parations made  for  a  resection  of  the  bowel.  Hydrocele  sac  was  opened  and  was 
lull  of  very  ofi^ensive  pus  and  feces;  it  contained  a  Richter  hernia  involving  four-fifths 
of  the  circumference  of  the  bowel,  which  was  gangrenous  and  had  perforated. 
Resection  of  five  inches,  end-to-end  approximation  with  button,  and  mass  returned 
to  abdomen.  The  hydrocele  cavity  was  left  open  and  packed  with  gauze.  Patient's 
condition  when  removed  from  the  operating  table  very  good.  Within  the  next  eight 
hours  after  operation  he  had  six  bowel  movements,  but  his  pulse  began  to  increase. 
He  had  no  pain,  tenderness,  tympanites,  nor  vomiting.  His  expression  became 
anxious  and  he  died  thirty  hours  after  the  operation  from  autointoxication. 

We  have  in  this  case  a  striking  illustration  of  the  importance  of  operating  where 
the  symptoms  of  vomiting  continue  after  the  non-operative  reduction  of  the  hernia. 
Furthermore,  we  have  an  additional  illustration  of  death  from  autointoxication  from 
the  absorption  of  the  decomposed  proteids  that  have  been  retained  in  the  intestinal 
canal.  In  this  case  it  could  not  be  attributed  to  the  thrombosed  veins,  as  they  were 
resected.  The  drainage  of  the  proximal  coil  at  the  time  of  operation  is  a  life-sav- 
ing procedure.  The  Moynihan  glass  tube  insertion  method  or  multiple  puncture  may 
be  resorted  to. 

Treatment. 
The  treatment  of  ileus  must  necessarily  depend  upon  the  differential  diagnosis 
or  etiologic  factor  in  the  production  of  its  symptoms.     The  treatment  may  well 
be  divided  into  three  classes,  corresponding  with  the  classification  of  ileus  given 


412  INTESTINAL   SURGERY. 

above.  The  adynamic  type  requires  no  surgical  treatment  as  far  as  the  ileus  itself 
is  concerned.  Still  each  of  its  subdivisions  has  distinct  and  clean-cut  therapeutic 
indications,  many  varieties  necessitating  immediate  surgical  intervention  not  for 
the  intestinal  obstruction  but  for  the  pathologic  conditions  producing  the  symptoms 
of  ileus.  In  fractures  of  the  spine  and  injuries  to  the  afferent  nerve  the  abdominal 
distention  is  relieved  by  paralyzing  the  sphincter  ani  by  overstretching,  as  in  the 
operation  for  hemorrhoids  and  by  passing  a  high  rectal  tube.  In  from  five  to 
seven  days  after  the  fracture  peristalsis  is  restored  and  the  distention  rapidly  sub- 
sides. Occasionally  the  tympany  is  so  great  as  to  compromise  respiration  and 
cardiac  action,  necessitating  an  enterostomy.  Reflex  ileus  is  relieved  by  large 
doses  of  morphin  and  atropin  combined,  or  the  latter  alone,  -^-q  to  -^-^  grain  doses. 
The  salicylate  of  physostigmin  and  eserin  in  large  doses,  -^  to  g^g-  of  a  grain  hypo- 
dermatically,  have  a  similar  effect  in  the  restoration  of  intestinal  peristalsis.  The 
cause  of  the  reflex  ileus  should  be  removed,  whatever  it  may  be,  whether  it  be  a 
gall-stone,  renal  calculus,  strangulated  omentum,  etc.  In  the  diaphragmatic 
pleurisy  ileus  large  doses  of  morphin  have  the  best  effect.  None  of  these  drugs, 
however,  should  ever  he  administered  until  a  positive  diagnosis  of  the  etiologic  factor  is 
made,  as  morphin  would  obscure  the  symptoms  of  a  mechanical  as  well  as  those  of  a 
reflex  ileus  and  contribute  nothing  to  its  cure.  In  the  ileus  of  intra-abdominal 
infections,  early  drainage  with  removal  of  the  cause  of  the  infection  is"  essential 
to  the  relief  of  the  symptoms.  It  is  of  vital  importance  to  the  patient  that  it  be 
timely.  It  should  be  borne  in  mind  that  one  of  the  most  important  symptoms 
in  the  differentiation  of  this  from  the  mechanical  type  is  the  uniform  elevation 
of  temperature  in  the  septic  variety  and  its  invariable  absence  in  the  mechanical 
variety.  Gastric  lavage  gives  great  relief  to  the  patient  in  all  types  of  adynamic 
ileus. 

The  dynamic  type  is  relieved  by  morphin,  atropin,  and  eserin.  The  elimination 
of  the  lead  when  this  is  the  cause  should  be  favored  by  every  possible  means  to 
prevent  a  recurrence  of  the  attacks.  Susceptible  patients  should  change  their 
occupation.  In  the  ptomain  and  tyrotoxicon  poisoning  gastric  and  intestinal 
lavage  with  proctoclysis  may  tide  the  patient  over  the  period  of  danger.  Here 
morphin  should  never  be  given,  as  it  lessens  peristalsis  and  retards  elimination, 
thereby  increasing  the  duration  and  degree  of  absorption. 

The  treatment  of  mechanical  ileus  consists  in  the  mechanical  removal  of  the 
cause  of  the  obstruction.  This  presupposes  a  positive  differential  diagnosis  which 
recjuires  a  most  careful  analysis  of  the  symptoms,  the  time  of  their  onset,  the  fre- 
quency of  their  manifestation,  the  rapidity  of  their  increase,  their  location,  etc. 
Even  those  most  experienced  can  err  as  to  the  etiologic  factors.  The  most  frequent 
errors  occur  in  differentiating  mechanical  ileus  from  (a)  cholelithic  colic,  (h)  ureteral 
colic,  (c)  tabetic  crises,  (d)  torsion  of  tumor  pedicles,  (e)  acute  pancreatic  fat  necrosis, 
(/)  peritonitis,  appendical,  perforative  (of  the  stomach,  intestine,  gall-bladder, 
tubes,  etc.).  It  is  embarrassing  to  the  surgeon  after  he  has  exercised  all  means  of 
diagnosis  to  operate  and  find  that  the  case  is  one  of  the  above  and  not  one  of  true 


ILEUS — INTESTINAL    OBSTRUCTION.  413 

mechanical  obstruction.  But  that  sin  of  commission  is  venal  and  rarely  com- 
mitted compared  to  the  frequent  mortal  one  of  ("conservative")  omission. 

When  operation  is  deferred,  deferred,  and  deferred  until  the  patient  is  collapsed, 
it  then  offers  no  hope.  There  has  been  no  treatment  so  far  instituted  that  materially 
reduces  the  mortality  in  cases  suffering  from  collapse  at  the  time  of  surgical  inter- 
vention for  mechanical  obstruction :  they  practically  all  die.  The  physician  and 
surgeon,  therefore,  must  be  keen  as  to  the  situation  and  see  that  surgical  relief  is 
given  before  the  symptoms  of  collapse  manifest  themselves.  Morphin,  atropin, 
and  eserin  are  all  equally  worthless  in  mechanical  ileus;  they  are  worse  than  that, 
for  they  encourage  delay,  dispel  the  symptoms  and  signals  of  danger,  and  give 
hope  when  none  is  justified  by  their  administration. 

Frequent  gastric  lavage  relieves  the  emesis,  retards  collapse,  and  should  be 
resorted  to  only  while  the  patient  is  being  hurried  to  the  operating  table,  for  while 
gastric  lavage  relieves  emesis  and  retards  the  collapse  it  also  retards  the  operation 
by  giving  the  surgeon  and  patient  rehef  from  the  condition  and  becomes  therefore 
an  element  of  danger  to  the  patient.  The  circumstances  under  which  this  is  most 
dangerous  is  the  ipost-ojperative  mechanical  ileus.  It  leads  one  on  and  on  in  the  delu- 
sion that  the  patient's  condition  is  improving,  while  in  reality  the  mechanical  obstruc- 
tion continues;  the  patient's  pulse  then  suddenly  rises  to  130  or  140,  the  abdomen 
is  reopened  to  reveal  the  lamentable  destructive  effects  of  the  prolonged  strangula- 
tion of  a  coil  of  bowel;  it  is  freed  with  or  without  resection  and  still  the  patient 
promptly  dies  from  that  fatal  and  so  far  irremediable  collapse.  When  post-oper- 
ative emesis  is  recurrent  after  forty-eight  hours  and  not  relieved  by  a  single  or 
double  gastric  lavage;  with  gastric  tetany  and  a  few  other  common  conditions 
excluded,  the  patient  should  then  and  there  be  reopened. 

The  treatment  of  mechanical  ileus  must  consist  in  the  early  mechanical  removal 
of  the  obstruction.  In  contrasting  the  statistics  of  recoveries  from  ileus  by  the 
medical  and  operative  treatments,  one  must  not  be  led  into  the  belief  that  a  mechan- 
ical obstruction  often  relieves  itself  or  is  often  relieved  by  medical  treatment.  The 
latter  I  believe  is  never  true,  the  former  rarely  occurs.  The  reason  for  the  common 
belief  in  the  profession  that  treatment  relieves  mechanical  ileus  is  entirely  due  to  the 
fact  that  a  differential  diagnosis  has  not  been  made  between  the  mechanical  and 
the  dynamic  and  adynamic  varieties.  There  is  no  "palliative"  or  conservative 
treatment  for  mechanical  ileus — "criminal  procrastination"  is  the  proper  term  for 
this  so-called  treatment. 

There  is  a  preparatory  treatment  mentioned  above  to  be  carried  out  while 
rapid  preparations  are  in  progress  for  an  efficient  operation  by  a  competent  operator. 
The  details  of  the  operative  procedures  for  mechanical  ileus  are  given  under  separate 
headings  to  follow. 

Towel  Method  of  Replacement. — Surgeons  of  experience  know  how  difficult 
it  is  to  replace  the  bowels  after  they  have  been  out  for  a  considerable  length  of  time 
during  an  operation  for  obstruction,  even  when  protected  by  hot  applications. 
The  causes  of  this  difficulty  are:    (1)  Usually  before  the  operation  the  bowels  are 


414  INTESTINAL   SURGERY. 

full  of  gas  (tympanitic)  from  the  diseased  condition  demanding  the  operation. 
(2)  During  the  exposure  the  intestinal  wall  becomes  edematous  and  a  large  transuda- 
tion of  fluid  into  the  intestinal  canal  takes  place.  The  bowel  when  eviscerated  is 
light  and  its  wall  thin  and  pliable;  in  half  an  hour  it  becomes  heavy  and  sodden, 
resembling  sausage.  These  changes  make  it  difficult  to  replace  the  intestines  into 
the  abdominal  cavity.  Some  operators  resort  to  puncture  of  the  bowel  to  relieve 
the  distention  and  thus  facilitate  the  replacement.  In  a  number  of  cases  I  have 
used  the  following  method  of  returning  the  bowel.  Cover  the  entire  intestinal  mass 
with  a  hot  towel,  placing  the  edge  of  the  towel  inside  the  margin  of  the  wound  all  the 
way  around.  This  acts  as  an  artificial  abdominal  wall  and  resembles  an  enormous 
ventral  hernia  with  a  large  neck  or  opening.  The  operator  and  assistant  then 
work  or  press  the  edge  of  the  towel  under  the  vsall  on  all  sides  with  the  fingers,  at  the 
same  time  elevating  the  abdominal  wall  with  retractors,  thus  forcing  the  mass  doAvn 
to  a  level  with  the  abdomen.  The  reduction  is  effected  in  this  manner  as  easily  as  a 
hernia  is  reduced  after  the  ring  has  been  enlarged.  The  sutures  are  then  inserted, 
and  as  they  are  tied  the  towel  is  gradually  withdrawn. 

Collapse  and  depression  in  association  with  intestinal  obstruction  may  be  divided 
into  three  classes:  (a)  Primary  shock  or  collapse,  due  to  the  reflex  effect  of  the  trauma 
to  the  strangulated  coil,  intussusception,  or  volvulus.  This  primary  shock  is  more 
pronounced  the  nearer  the  strangulation  is  to  the  origin  of  the  jejunum,  the  greater 
the  coil,  and  the  greater  the  tension  under  which  the  contents  of  the  strangulated 
coil  is  held,  (b)  Intermediate  depression,  collapse,  or  shock;  a  mild  degree  of 
cyanosis,  gradually  increasing,  associated  often  with  persistent  vomiting;  the  collapse 
and  the  vomiting  are  less  the  closer  the  obstruction  is  to  the  origin  of  the  jejunum. 
This  depression  is  due,  we  believe,  to  the  continued  vomiting,  distention,  and  ab- 
sorption wliich  take  place  above  the  point  of  obstruction,  (c)  Post-operative  collapse, 
usually  a  sequence  of  late  operations,  occurs  either  with  or  without  resection  of  the 
bowel,  and  without  peritonitis.  It  begins  to  assert  itself  shortly  after  operation, 
is  not  associated  with  vomiting,  and  proceeds  to  a  fatal  termination  six  or  eight  hours 
after  the  bowel  has  been  freed.  Since  1892  we  have  maintained  that  this  collapse  is 
due  to  the  absorption  of  the  poisonous  intestinal  contents  which  starts  in  suddenly 
both  above  and  below  the  point  of  obstruction  after  the  bowel  has  been  freed.  The 
conditions  are  relieved  (a)  by  hypodermic  injections  of  anod}Ties,  which  should  never 
be  given  except  preparatory  to  operation ;  (b)  by  repeated  gastric  lavage  and  proc- 
toclysis, also  preparatory  to  operation;  (c)  by  opening  the  bowel  above  the  point  of 
obstruction,  thoroughly  emptying  it  over  a  glass  (Moynihan)  or  rubber  tube  at  the 
time  of  the  operation ;  this  should  be  followed  by  repeated  gastric  lavage  and  proc- 
toclysis immediately  after  the  operation.     The  technic  of  proctoclysis  is  as  follows: 

1.  A2-quart  fountain  syringe  should  be  attached  to  the  head  or  foot  of  the  bed, 
and  elevated  from  4  to  18  inches  as  required  to  counteract  the  intra-abdominal  pres- 
sure. 

2.  The  vaginal  hard-rubber  douche  tip  flexed  at  35  degrees  (2]  inches  from  the 
end)  should  be  inserted  into  the  rectum.     This  should  be  attached  to  a  rubber  tube 


ILEUS — INTESTINAL    OBSTRUCTION. 


415 


which  is  secured  to  the  thigh  with  a  firm  adhesive  strap  so  as  to  prevent  displacement 

of  the  tip. 

3.  Salt  solution  at  a  temperature  of  100°  should  be  allowed  to  flow  in  until  1^ 
to  2  pints  have  been  taken.  This  should  require  at  least  sixty  minutes,  and  must  be 
controlled  by  the  elevation  of  the  syringe  and  never  by  a  forceps  applied  to  the  tube 
to  lessen  its  lumen,  as  this  would  prevent  a  rapid  return  flow  to  the  can  or 
escape  of  gas,  should  the  patient  cough  or  strain.  The  quantity  should  be 
repeated  every  two  hours.  Never  remove  the  rectal  tube  except  for  defeca- 
tion.    When  the  fluid  is  not  retained  it  is  improperly  given.     I  have  had  a 


Fig.  622. — Murphy's  Method  of  Proctoclysis. 
a,  Adhesive  plaster  fastening  the  tube  to  the  inner  aspect  of  the  thigh;    b,  rubber  tube  with  tip  inserted  in  the 

rectum. 

child  retain  30  pints  in  twenty-four  hours.     Tide  the  patient  over  the  immediate 
effects  of  the  toxemia  the  same  as  over  acute  alkaloid  poisoning  and  he  will  recover. 


Post-operative  Intestinal  Paralysis  and  Intestinal  Obstruction. 
Post-operative  ileus  is  unfortunately  far  from  rare.     Fritsch,'  for  example,  lost 
1.6  per  cent,  of  all  laparotomies  from  post-operative  ileus. 

To  better  understand  the  etiologic  factors  of  post-operative  intestinal  obstruction 
the  condition  must  be  divided  into  two  distinct  classes : 

>Fritsch,  H.:  Bericht  u.  die  Gynakolog.  Operationen  d.  Jahrg.  1891-1892,  p.  213. 


416  INTESTINAL    SURGERY. 

(a)  Adynamic  or  functional  paralytic  ileus. 

(b)  Mechanical  or  organic  ileus. 

The  former  of  these  classes  is  due  to  intestinal  paresis,  trauma,  exposure,  fixation, 
peritonitis,  mural  infiltration,  and  over-distention  of  the  walls  of  the  bowel. 

Organic  ileus  is  caused  by  protrusion  of  intestine  into  peritoneal  pockets; 
transfixion  of  the  intestine  while  closing  the  wound;  compression  of  the  coils  between 
the  stitches;  incarceration  of  a  loop  in  a  hole  in  the  omentum  or  mesentery;  in- 
clusion of  a  coil  of  intestine  between  the  margins  of  the  wound  after  vaginal  hys- 
terectomy; plication  of  the  intestinal  wall  due  to  several  abraded  areas;  vol- 
vulvus;  bands  of  adhesions  compressing  the  bowel;  hematoma  of  the  lower  pelvis 
following  vaginal  hysterectomy;  necrosis  and  cicatrices  following  trauma  of  the 
mesentery;   accordion  plications  v>'ith  adhesions,  etc. 

The  follov/ing  classification  will  facilitate  the  understanding  of  the  etiologic 
factors  of  post-operative  ileus: 

1.  Trauma  of  the  peritoneum  and  intestinal  wall,  including  also  simple  ex- 
ploratory operations. 

2.  Reflex  causes,  such  as  the  ligation  of  pedicles,  tension  sutures,  etc. 

3.  Agglutination  of  the  intestinal  coils. 

4.  Peritonitis. 

Intestinal  paresis  and  paralysis  are  due  most  frequently  to  peritonitis.  ReicheP 
found  that  after  a  laparotomy  the  peritoneum  may  be  infected  by  bacteria,  not  only 
from  without,  but  also  from  within  the  bowel.  ?vIultanowsky^  has  proved  that  in 
case  of  arrest  of  the  feces  in  the  intestine,  the  colon  bacillus  and  many  other  species 
of  bacteria  may,  after  this  has  persisted  for  six  hours,  pass  through  the  wall  of  the 
intestine  and  infect  the  peritoneum,  even  though  the  serous  coat  of  the  latter  is  in- 
tact.    This  I  have  demonstrated  many  times  in  the  sacs  of  strangulated  hernias. 

During  laparotomies  the  intestines,  almost  or  completely  collapsed  at  the  be- 
ginning, may  become  distended  toward  the  close.  Fritsch^'  attributes  this  to  the 
swallowing  of  air  during  narcosis.  In  1896  we  demonstrated  experimentally  that  the 
enlargement  is  due  to  venous  and  peristaltic  stasis.  When  the  intestines  are  pushed 
back  forcibly,  a  kink  may  result,  and  becoming  adherent  produce  obstruction. 

The  diagnosis  of  post-operative  intestinal  obstruction  is  sometimes  easy,  the 
cardinal  symptoms — pain,  vomiting,  coprostasis,  and  meteorism — being  classic. 
Again,  the  diagnosis  may  be  very  difficult  when  the  cHnical  picture  is  that  of  peri- 
tonitis. Veit  states  that  when  the  first  week  is  afebrile,  and  such  symptoms  occur 
later,  it  is  suggestive  of  post-operative  ileus.  In  septic  peritonitis  the  symptoms  of 
ileus  last  for  three,  four,  five,  or  six  days,  during  which  time  it  is  impossible  to  secure 
a  fecal  evacuation.  Very  often  just  before  death  there  is  active  peristalsis  with  a 
watery  discharge.  This  to  the  inexperienced  is  a  favorable  omen,  while  it  should  be 
interpreted  as  a  precursor  of  death. 

It  is  at  times  very  difficult  to  dift'erentiate  the  adynamic  variety  of  post-operative 

iReichel:  "Die  Entstehung  der  Missbildungen  der  Harnblase  und  Harnrohre,"  Centralbl.  f. 
Chir.,  1894,  xxi,  823. 

^Multanowsky:  Inaug.  Dissert.,  St.  Petersburg,  1895.  ^pj-itsch:  Op.  cit. 


ILEUS — INTESTINAL    OBSTRUCTION.  417 

obstruction  from  the  mechanical.  As  a  result  of  clinical  experience,  however,  we 
have  learned  that  in  the  adynamic  form  the  symptoms  appear  early,  rarely  later  than 
forty-eight  hours.  Vomiting  is  marked  in  the  beginning,  but  diminishes  with  time; 
the  pain  is  not  of  a  colicky  character  and  collapse  is  present,  but  not  as  early  as  in 
the  mechanical  form. 

Treatment. — I  am  fully  convinced  that  the  prejudice  of  the  previous  decade 
not  to  reopen  the  abdomen  was  erroneous,  and  has  contributed  materially  to  the  post- 
operative mortality.  At  present  if  a  patient  presents  himself  at  a  hospital  with 
symptoms  of  ileus  or  any  other  serious  abdominal  manifestation  in  which  no  definite 
diagnosis  can  be  made  at  once,  he  is  immediately  laparotomized.  Few  surgeons, 
however,  reopen  the  abdomen  when  the  same  train  of  symptoms  follows  a  lapar- 
otomy in  time  to  save  the  patients  from  the  disastrous  results  of  the  post-operative 
obstruction.  The  surgeon  is  often  chagrined  to  find  from  the  necropsy  that  the 
condition  causing  death  was  purely  mechanical  or  one  which  could  have  been  readily 
rectified  by  an  operation. 

The  treatment  of  post-operative  ileus  can  be  classified  as  medical  and  surgical. 
Before  entering  into  a  detailed  consideration  of  the  treatment,  I  wish  to  call  attention 
to  the  fact  that  while  abdominal  distention  after  operation  is  generally  considered  a 
manifestation  of  retention,  we  estimate  this  immediate  distention  as  of  prophylactic 
value  against  organic  fixation  and  paralytic  ileus.  It  seems  to  be  Nature's  effort  to 
prevent  post-operative  ileus.  As  a  general  rule,  in  traumatic  peritonitis  the  ileus 
subsides  in  a  comparatively  short  time;  in  septic  peritonitis  it  is  entirely  different — 
the  ileus  is  pronounced  and  prolonged.  Associated  with  elevation  of  temperature, 
rapid  pulse,  anxious  expression,  and  the  other  symptoms  making  up  the  clinical 
picture  of  septic  peritonitis,  the  treatment  should  be:  drainage,  streptolytic  serum, 
continuous  proctoclysis  with  normal  salt  solution,  inunctions  with  unguentum 
Crede,  and  Fowler's  position.     The  ileus  is  only  a  manifestation  of  the  peritonitis. 

In  order  to  prevent  post-operative  ileus  many  operators  advise  giving  a  purgative 
a  few  hours  before  the  operation;  it  does  not  seem  to  make  any  material  difference 
which  purgative  is  chosen.  In  my  practice  I  do  not  follow  this  method.  If  some 
time  after  the  operation,  say  six  to  twelve  hours,  or  the  next  day,  the  patient  has 
nausea  or  vomiting,  gastric  lavage  is  resorted  to  and  is  very  effectual  in  relieving  the 
distress.  In  order  to  stimulate  peristalsis  calomel  is  given  in  fractional  doses  after 
the  operation — 2V  ^r  tV  grain  every  fifteen  or  twenty  minutes  until  from  1  to  2  grains 
have  been  taken.  This  is  followed  by  a  saline.  When  there  is  a  paralysis  of  per' 
istalsis  strychnin  is  administered  in  ^-^  to  -^V  grain  doses.  Arndt,^  of  Posen,  fol- 
lowed by  many  others,  effectually  used  eserin  salicylate,  1  to  2  milligrams  (-^-q  to  3^ 
grain),  in  twenty-four  hours  in  case  of  threatened  or  pronounced  adynamic  post- 
operative ileus  with  good  results.  Physostigmin  salicylate  is  equivalent  to  eserin 
and  should  be  given  hypodermically  in  ^^^--grain  doses  repeated  every  hour  or  two 
for  as  many  as  six  doses.     Hypodermic  injections  of  -^^-q  gr.  of  atropin  sulphate  fre- 

*  Arndt,  Gustav:  "Das  Eserin  in  der  Behandlung  der  Postoperativen  Darmparalyse,"  Ztrb. 
f.  Gyn.,  1904,  No.  9,  S.  273. 
VOL.  II — 27 


418  INTESTINAL   SURGERY. 

qiiently  relieve  the  post-operative  colic.  These  medications,  however,  are  applicable 
only  to  the  adynamic  type  or  wind  colic  varieties  of  ileus,  and  have  no  effect  in  the 
mechanical  variety. 

Hardon^  reports  that  42  per  cent,  of  the  deaths  in  abdominal  surgery  in  his  first 
seven  years  of  practice  was  due  to  "  intestinal  paresis."  In  the  last  nine  years  of  his 
practice  he  has  had  no  cases  of  paresis,  which  he  attributes  to  the  beneficial  effects 
of  enemata  1  to  2  pints  of  alum  solution,  3  to  5  per  cent.,  given  shortly  after  the 
operation.  This  agent  is  known  to  increase  the  peristaltic  activity.  In  a  limited 
experience  I  have  also  found  it  very  efficacious. 

Post-operative  ileus  is  rather  a  rare  occurrence  in  the  writer's  practice,  and  this 
he  attributes  to  the  scrupulous  avoidance  of  trauma  during  the  operation,  as  well  as 
to  the  post-operative  management  of  the  cases.  Shortly  after  every  prolonged, 
severe,  or  septic  laparotomy,  except  in  those  where  intestinal  approximation  or 
anastomosis  of  the  large  intestine  has  been  performed,  continuous  proctoclysis  is 
practised  as  described  above. 

In  the  presence  of  mechanical  ileus  when  meteorism,  coprostasis,  and  pain  extend 
beyond  forty-eight  hours,  the  treatment  must  not  be  expectant.  Reopening  of  the 
abdomen  is  indicated  particularly  when  there  is  no  elevation  of  temperature.  If  post- 
operative ileus  follows  a  vaginal  hysterectomy,  there  is  no  occasion  for  making  an 
abdominal  incision.  The  vaginal  packing  or  the  clamps  (if  these  have  been  used) 
can  be  easily  removed,  the  cause  detected,  and  the  obstruction  overcome. 

Operative  Treatment. — When  the  obstruction  is  not  overcome  by  the  treatment 
described  in  the  foregoing  section,  the  abdomen  should  be  reopened  in  the  operating 
room,  with  all  the  preparations  and  precautions  that  are  resorted  to  in  primary  sec- 
tions. The  stitches  should  be  freely  removed  and  the  site  of  the  former  operation 
carefully  inspected,  as  a  collection  of  blood  or  wound-secretion  may  be  found  com- 
pressing the  bowel.  Search  should  be  made  for  a  coil  of  distended  intestine,  leading 
to  a  collapsed  zone.  It  should  be  borne  in  mind  that  the  large  intestine  is  often 
distended  when  the  obstruction  is  above  the  ileocecal  valve.  In  the  small  intestine 
the  point  distal  to  the  point  of  obturation  is  always  collapsed.  The  collapsed  coils 
should  be  lifted  up  and  rapidly  run  through  the  fingers  within  the  abdomen  until  they 
cease  to  come  freely,  when  a  careful  examination  will  reveal  the  cause  of  the  obstruc- 
tion, which  should  be  removed,  the  intestine  straightened  out,  and,  if  necessary, 
a  resection  should  be  made  of  severely  strangulated  coils.  The  liberation  must  con- 
tinue along  the  coil  until  the  distended  zone  is  reached,  otherwise  a  second  obstruc- 
tion might  be  overlooked. 

The  obstruction  is  not  always  at  the  seat  of  operation ;   for  example,  eight  days 

following  an  operation  for  ruptured  ectopic  gestation  the  usual  train  of  symptoms  of 

ileus  presented  themselves.     A  careful  separation  of  all  the  adherent  intestines, 

blood-clot,  tube,  stump,  etc.,  failed  to  reveal  the  junction  of  the  distended  portion 

with  the  collapsed  coil.     Proceeding  upward  to  the  jejunal  mesentery  the  writer 

found  a  volvulus  including  4  feet  of  jejimura.     This  was  held  securely  in  its  place 

'  Hardon,  V.  O.:    "The  Alum   Enema  in  the  After-treatment  of  Abdominal  Operations," 
Amer.  Jour,  of  Obstet.,  1901,  xliii,  p.  786. 


ULCERS.  419 

by  slight  adhesions.  These  were  separated,  the  bowel  restored  to  its  normal 
position,  and  the  patient  recovered. 

It  is  surprising  to  see  how  apparently  friable  adhesions  will  hold  the  intestine 
firmly  enough  to  produce  obstruction. 

There  are  three  points  at  which  obstruction  may  occur,  which  are  usually 
overlooked.  These  are:  (1)  The  duodenojejunal  fossae;  (2)  the  cecal  fossae;  and 
(3)  the  sigmoid  fossa. 

When  the  intestine  is  incarcerated  in  either  of  the  first  two,  it  is  likely  to  be  over- 
looked and  its  fixation  attributed  to  the  normal  mesenteric  attachment  at  these 
positions,  on  account  of  their  relation  to  the  normal  anatomic  upper  and  lower 
terminations  of  the  small  intestine,  while  in  reality  the  bowel  has  become  stran- 
gulated in  one  of  these  peritoneal  pockets.  This  error  is  more  common  in  the  ex- 
amination of  post-operative  than  in  the  primary  variety  of  ileus. 

If  septic  peritonitis  is  present  it  will  be  benefited  by  the  opening  of  the  peritoneum, 
lessening,  as  the  latter  does,  the  tension  of  the  infection  products,  diminishing  the 
absorption,  and  often  furnishing  life-saving  drainage,  though  laparotomies  for  post- 
operative are  not  at  all  as  successful  as  those  for  primary  septic  peritonitis.  If  the 
distention  of  the  coils  of  intestine  is  great,  it  may  be  relieved  by  many  punctures  with 
a  hollow  needle;  these  should  be  sutured  at  once.  This  method  is  better  than  an  in- 
cision, and  should  be  performed  rapidly.  There  is  less  danger  of  infecting  the  peri- 
toneum by  a  secondary  opening  than  by  a  primary  one,  as  its  local  resistance  has  been 
developed  by  infiltration  (which  means  local  resistance)  from  the  first  intervention. 

Drainage  may  or  may  not  be  used  following  the  second  operation.  Its  use  is 
governed  by  the  same  indications  as  in  the  primary  operation.  A  secondary  opera- 
tion permits  primary  union  of  the  wound  margins  as  readily  as  the  first  one. 

The  high  mortality  of  secondary  laparotomies  is  due  not  to  the  operation  itself, 
but  to  the  fact  that  the  secondary  operation  is  delayed  until  irreparable  pathologic 
conditions  have  developed.  Secondary  openings  should  be  made  whenever  the  post- 
operative symptoms  are  inconsonant  with  the  usual  process  of  repair  from  the 
pathologic  conditions  found  in  the  primary  operation.  It  may  seem  needless  to 
warn  against  mistaking  acute  gastric  dilatation  or  symptoms  of  uremia  for  mechan- 
ical ileus,  but'  this  has  frequently  occurred. 

ULCERS. 

The  alimentary  canal  is  a  favorite  seat  of  ulceration,  and  while  no  portion  is 
exempt,  there  are  favored  ulcer  zones. 

Peptic  Ulcer;  Round  DuodenalUlcer ;  Ulcus  Duodeni  Pepticum  (LeubeM- 
— This  variety  is  less  common  than  the  gastric  (as  1  :  12,  BurwinkeP;  1  :  3,  jNIayo^), 

^  Leube,  O.  W. :  "Die  Krankheiten  des  Mac;ens  und  Darms."  Von  Ziemssen's  Handbiich, 
1876,  vii,  2. 

^  Burwinkel,  O.:  "Klinische  Beobachtungen  iiber  das  peptische  Duodenalgesclnvur,"  Dentsch. 
med.  Woch.,  1898,  xxiv,  Nr.  52,  823. 

^  Mayo,  W.  J.:  "The  Surgical  Treatment  of  Gastric  and  Duodenal  Ulcer  and  Its  Results," 
Jour.  Amer.  Med.  Assoc,  1906,  xlvii,  912. 


420  INTESTINAL   SURGERY. 

and,  unlike  the  latter,  is  most  frequent  in  men  (3:1).  It  is  not  infrequently  as- 
sociated with  gastric  ulcer — a  matter  not  to  be  overlooked. 

The  corrosive  action  of  the  gastric  juice  is  not  limited  to  the  stomach,  but  attacks 
the  esophagus  occasionally  and  the  duodenum  frequently,  rarely  the  jejunum  after 
gastro-enterostomy. 

Duodenal  ulcers  are  located  most  frequently  in  the  upper  part  of  the  duodenum 
before  the  acid  chyme  has  been  neutralized  by  the  bile  and  the  pancreatic  juice. 
If  situated  at  the  pylorus,  they  may  involve  both  the  gastric  and  duodenal  mucosae 
and  assume  an  hour-glass  shape.  The  anterior  wall  of  the  duodenum  is  the  most 
common  site;  they  are  usually  single,  though  as  many  as  thirty  have  been  observed 
in  one  case.  W.  J.  and  C.  H.  Mayo,^  who  have  had  a  most  extensive  experience, 
observed  one  hundred  and  thirty-five  cases  of  duodenal  ulcer  to  twenty-eight 
cases  of  gastric  and  duodenal  ulcers  combined.  Of  these,  77  per  cent,  were 
in  males  and  23  per  cent,  in  females.  In  all  but  five  cases  the  bowel  lesions 
were  single. 

These  ulcers  are  most  common  between  the  ages  of  thirty  and  sixty;  unlike  the 
gastric  variety,  which  is  very  rare  in  children,  the  duodenal  variety  is  somewhat 
common  under  ten.  They  have  even  been  found  in  new-born  babes  who  had  sur- 
vived but  a  few  hours,  hence  they  may  arise  in  utero.  The  etiologic  factors  which 
give  rise  to  duodenal  ulcers,  though  not  definitely  known,  are  apparently  the  same 
as  in  the  gastric  type.  They  may  be  grouped  in  the  order  of  their  importance  as 
follows:  Hyperchlorhydria,  local  infection,  embolism  or  thrombosis,  and  foreign 
bodies.  Autodigestion  of  a  zone  of  ischemic  mucosa  appears  to  play  the  most  im- 
portant role  in  the  production  of  gastric  and  duodenal  ulcers.  In  size  the  ulcers 
vary  from  1  to  3.5  cm.  in  diameter.  If  perforation  takes  place,  the  opening  is  usually 
much  smaller  than  the  ulcer  itself,  being  rarely  larger  than  0.6  cm.  in  diameter. 
The  small  ulcer  is  more  prone  to  deep  destruction  and  perforation  than  the  large. 
They  generally  perforate  into  the  free  abdominal  cavity,  without  inducing  protec- 
tive adhesions  of  the  neighboring  viscera  before  perforating;  in  rare  cases  into  the 
pancreas,  the  liver,  the  gall-bladder,  or  some  of  the  large  blood-vessels  in  the  vicinity. 
In  the  former  the  fluid  escaping  from  the  viscus  is  free  to  run  at  large  in  the  abdomen. 
In  many  cases  a  well-defined  path  is  taken.  The  fluid  (generally  mucus  more  or 
less  tinged  with  bile)  escapes  upon  the  upper  surface  of  the  transverse  mesocolon  to 
the  right  of  the  hillock  which  is  formed  by  the  fitting  in  of  the  transverse  colon  to  the 
greater  curvature.  It,  therefore,  tends  to  run  to  the  right  on  the  hepatic  flexure  and 
then  to  descend  to  the  iliac  fossa  aJong  the  outer  side  of  the  ascending  colon.  Col- 
lecting there,  it  may  cause  symptoms  strongly  suggestive  of  appendicitis,  and  has 
been  frequently  erroneously  diagnosed  as  such.  From  the  iliac  fossa  the  fluid  drains 
to  the  pelvis,  and,  filling  that,  overflows  into  the  left  iliac  fossa.  If  an  abscess 
forms  it  may  be  bounded  by  lymph,  agglutinations  or  adhesions  of  liver,  intestines, 
omentum,  etc. 

That  duodenal  iflcers  heal  spontaneously  is  proved  by  post-mortem  findings. 

^  Mayo:  Loc.  cit. 


ULCERS.  421 

The  tendency  to  the  development  of  carcinoma  in  the  scars  is  not  nearly  so  great  as 
in  gastric  ulcer,  though  authentic  cases  are  recorded  in  the  literature. 

The  sijmj)tomatology  is  notoriously  uncertain  and  inconstant.  Of  one  hundred 
and  fifty-one  cases  collected  by  Perry  and  Shaw/  ninety-one  gave  rise  to  no  symp- 
toms of  moment  until  hemorrhage  or  perforation  took  place.  The  pain  in  general 
may  be  said  to  resemble  that  of  gastric  ulcer,  but  it  is  usually  much  less  severe, 
because  the  duodenum  is  more  fixed  and  the  stomach  contents  are  less  irritating. 
In  some  cases  it  is  merely  a  sense  of  discomfort,  while  in  few  it  is  severe  and  intoler- 
able. Its  character  is  burning  or  "boring,"  and  it  may  radiate  down  and  to  the 
sides;  seldom  or  never  to  the  back.  It  comes  on  from  one-half  to  six  hours  after  a 
meal,  but  is  characteristic  when  it  makes  its  appearance  from  two  to  four  hours  after 
a  meal.  In  some  cases  the  pain  has  been  sudden  in  its  onset  and  colicky,  resem- 
bling the  colicky  type  of  gastric  ulcer,  so  often  emphasized  by  us,  and  also  mimick- 
ing that  of  gall-stones.^  In  our  observations  demonstrated  by  the  pathologic  find- 
ings at  the  operation,  one  of  the  contrasting  characteristics  between  the  pain  of 
gastric  ulcer  and  that  of  duodenal  ulcer  is  that  in  the  former  the  pain  is  imme- 
diately increased — if  affected  at  all — by  the  food  (except  where  the  ulcer  is  in  the 
pyloric  zone),  while  in  the  latter  the  pain  is  promptly  relieved  by  the  ingestion  of 
food,  as  it  causes  a  suspension  of  chyme  transmission  through  the  pylorus. 

Hemorrhage  may  manifest  itself  either  through  the  stomach  or  bowel;  in  some 
cases  hematemesis  or  melena  is  the  first  symptom  to  attract  the  patient's  attention. 
It  is  found  in  26  per  cent,  of  the  acute  and  40  per  cent,  of  the  chronic  ulcers  (Fen- 
wick^). 

Vomiting  is  relatively  rare.  It  occurs  in  about  17  per  cent,  of  the  cases  (Oppen- 
heimer*),  and  is  not  usually  characteristic  unless  it  comes  on  from  two  to  four  hours 
after  a  meal.  It  often  takes  place  at  the  height  of  the  painful  paroxysm,  and  is  not 
always  dependent  on  taking  food. 

Icterus  is  rare.  When  present,  it  may  be  due  to  swelling  of  the  mucosa  of  the 
common  duct  in  the  acute  cases,  or  to  cicatricial  occlusion  in  the  cases  of  long  stand- 
ing. Other  symptoms  which  have  been  reported  are :  (a)  Digestive  disorders,  usu- 
ally resembling  hyperchlorhydria,  or  less  frequently  gastric  catarrh;  {b)  paroxysmal 
dyspnea,  the  origin  of  which,  though  not  certain,  is  probably  reflex;  (c)  neuralgias, 
also  reflex,  affecting  various  portions  of  the  abdomen  and  chest;  {d)  cardiac  palpi- 
tation. 

The  course  of  the  great  majority  of  cases  is  essentially  chronic  and  slowly  tends 
toward  spontaneous  recovery.  In  some  cases,  however,  as  previously  pointed  out, 
the  first  symptom  may  be  a  profuse  or  even  fatal  hemorrhage,  or  the  sudden  develop- 
ment of  a  general  peritonitis  due  to  the  perforation  of  the  ulcer. 

1  Perry  and  Shaw:  "On  Diseases  of  the  Duodenum,"  Guy's  Hospital  Reports.  1893,  xxxv, 
171. 

^  Graham:  "Diagnosis  between  Duodenal  Ulcer  and  Gall-stone  Disease,"  Jour.  Am.  Med. 
Assoc,  Feb.  9,  1907,  515. 

^  Fenwick:    "Ulcer  of  Stomach  and  Duodenum,"  Philadelphia,  1900. 
^  Oppenheimer:   Inaug.  Dissert.,  Wurzburg,  1891. 


422  INTESTINAL   SURGERY. 

The  treatment  of  the  acute  ulcer  is  medical;  surgery  has  to  do  only  with  the  com- 
plications, such  as  hemorrhage  and  perforation  (Mayo).  Secondary  cicatricial 
stenosis  is  more  common  than  is  usually  believed,  and  results  in  enormous  dilatation, 
even  involving  the  stomach.  The  duodenum  may  be  larger  than  the  stomach  and 
the  pylorus  mistaken  for  hour-glass  contraction  (see  the  illustration  of  Cordes's  case). 
When  perforation  takes  place,  the  patient  should  be  operated  on  as  soon  as  possible, 
as  the  statistics  show  that  the  earher  the  operation,  the  greater  the  chances  for 
recovery.  The  Mayos  have  made  one  hundred  and  thirty-five  "no-loop"  gastro- 
jejunostomies, with  but  one  death. 

In  these  cases  it  is  very  desirable  to  make  a  definitive  occlusion  of  the  pylorus. 
This  can  best  be  done  on  its  duodenal  side  by  freeing  it  from  its  mesentery  to  the 
extent  of  |  inch,  crushing  it  with  two  hysterectomy  clamps  closely  applied,  and 
dividing  the  duodenum  between  the  clamps.  A  Hgature  is  then  placed  on  each 
crushed  zone,  and  will  have  in  its  bite  only  the  fibrous  layer  of  the  bowel.  This 
can  be  readily  involuted  with  two  rows  of  continuous  Pagenstecher  Hnen  sutures. 
The  whole  operation  occupies  but  a  very  few  minutes,  and  permanently  protects  the 
duodenum  from  the  gastric  secretion. 

Follicular  or  Catarrhal  Ulcer. — This  variety  occurs  in  acute  or  chronic  in- 
flammation of  the  intestine,  and  is  not  so  common  in  the  small  as  in  the  large  bowel. 
This  ulcer  is  not  deep  and  it  soon  heals;  it  is,  therefore,  of  sHght  surgical  im- 
portance. 

Stercoral  Ulcer;  Decubital  Ulcer  (Grawitz^). — This  is  found  nearly  exclus- 
ivelv  in  the  large  bowel,  where  the  fecal  current  is  slowed  or  scybalous  masses  irri- 
tate—the cecum,  hepatic  and  splenic  flexures,  and  the  sigmoid.  For  this  reason 
they  are  also  common  above  strictured  portions  of  the  intestine.  They  may  be 
shallow  or  deep.     They  are  catarrhal  in  nature  and  may  be  followed  by  stricture. 

Typhoid  Ulcer. — While  this  variety  is  found  mostly  in  the  ileum,  it  may  in- 
vade the  gall-bladder,  the  stomach,  and  even  the  pharynx.  They  are  usually  op- 
posite the  mesenteric  attachment  and  vary  in  number  up  to  thirty-six.  Typhoid 
ulcers  usually  assume  the  shape  of  the  Peyer's  patch,  but  as  only  part  of  the  patch 
sloughs  off,  the  resulting  ulcer  will  be  very  irregularly  shaped.  The  edges  are  not 
indurated,  as  in  the  border  and  floor  of  tuberculous  ulcers. 

In  577  necropsies  they  were  located:  510  times  in  the  ileum;  247  times  in  the 
cecum  and  appendix;  184  times  in  the  colon;  41  times  in  the  jejunum;  12  times  in 
the  rectum  (Curschmann^). 

Perforation  is  estimated  by  Murchison  at  21  per  cent. ;  by  Curschmann  at  only 
10  per  cent.;  and  by  Osler^  at  1.2  to  3.6  per  cent.,  and  causes,  33.8  per  cent,  of  all 
deaths  from  the  disease. 

Site  of  the  perforation  in  167  cases:  Ileum,  136  times;  large  intestine,  20  times; 

1  Grawitz,Paul.:  "Statitischer  und  Experimentell-pathologischer  Beitrag  zur  Kenntniss  der 
Peritonitis,"  Charite-Ann. ,  1885,  xi,  770. 

2  Curschmann,  H.:  "Die  Anomalien  der  Lage,  Form  und  Grosse  des  Dickdarms  und  ihre 
klinische  Bedeutung,"  Arch.  f.  kUn.  Med..  1894,  liii,  1. 

3  Osier,  W. :  "Practice  of  Medicine,"  New  York,  1892. 


ULCERS. 


423 


As  a  rule, 


vermiform  appendix,  5  times;   Meckel's  diverticulum,  4  times;   jejunum,  2  times 
(Fitz^). 

The  typhoid  ulcer  becomes  surgical  only  when  it  perforates  the  intestine  or  per- 
mits of  a  peritoneal  infection  through  the  lymphatics.  In  either  case  the  peritonitis 
should  have  immediate  operative  treatment,  described  in  another  chapter.  The 
results  in  the  operative  treatment  of  typhoid  hemorrhage  do  not  justify  its  uniform 
practice  for  this  condition.  Operation,  however,  may  be  resorted  to  in  exceptional 
cases  with  advantage. 

Dysenteric  IJlcer. — This  variety  is  of  various  shapes  and  sizes,  either  confined  to 
restricted  areas,  or  practically  continuous  throughout  the  large  bowel.  They  also 
vary  greatly  in  size,  from  minute  points  up  to  l^r  or  2  inches  in  diameter, 
they  are  transverse  to  the  long  axis  of  the 
bowel.  They  may  involve  the  lower  ileum, 
but  in  general  they  are  found  in  the  large 
intestine  either  in  whole  or  in  part. 

Dysenteric  ulcers  may  perforate,  but 
it  is  now  known  that  their  healing  is  not 
attended  by  contraction  of  the  lumen. 
This  we  owe  to  the  researches  of  the  late 
J.  J.  Woodward,^  who  found  no  stenosis 
in  the  enormous  amount  of  material  col- 
lected by  him  for  the  "Medical  and  Surgi- 
cal History  of  the  War  of  the  Rebellion." 
When  severe  and  persistent,  an  appendi- 
costomy  (Weir^)  should  be  resorted  to  for 
the  continued  or  repeated  lavage  of  the 
large  intestinal  tract.  This  disease  shows 
at  times  intense  sepsis  and  great  tendency 
to  necrosis;  a  timely  appendicostomy 
materially  lessens  the  danger  and  hastens 
the  recovery. 

Bilharziosis  of  the  colon  is  also  attended  by  ulcers,  confined  to  the  mucosa. 

Tuberculous  Ulcer. — These  may  be  primary  or  secondary.  According  to 
Frerichs,  tuberculosis  of  the  ileum  is  found  in  80  per  cent,  of  the  cases  of  chronic 
pulmonary  tuberculosis.  The  tuberculous  ulcers  are  observed  principally  in  the 
lower  part  of  the  ileum  and  run  transversely  to  the  axis  of  the  bowel.  Tuberculous 
deposits  may  be  seen  as  a  white  line  running  from  the  ulcer  into  the  mesentery. 
They  are  of  irregular  shapes,  undermined  or  smooth.  They  rarely  cicatrize; 
hemorrhage  is  infrequent  and  usually  gives  a  premonitory  symptom — sudden  elevation 


Fig.    623. — Tuberculous    Granuloma    Producing 

Obstruction  of  the  Bowel. 
a,  Cicatricial  tissue;  b,  stenosis;  c,  distal  end;  d,  proxi- 
mal end. 


'  Fitz,  R.  H.:     "Typhloenteritis  and  Appendicitis,"   Boston  Med.  and  Surg.  Jour.,   1890, 
cxxii,  167. 

2  Woodward,  J.  J.:   "Med.  and  Surg.  Hist,  of  the  Rebellion,"  Medical  vol.  i,  part  2. 

'Weir,  R.  F.:  Med.  Record,  Aug.,  1902. 


424 


INTESTINAL   SURGERY. 


of  temperature — and  is  frequently  accompanied  and  followed  by  intestinal  cramps. 
Perforation  is  not  common  (8  to  10  per  cent.);  it  is  slow,  hence  perforation  into  the 
free  peritoneal  cavity  is  rare;  the  opening  is  usually  into  some  recess  walled  off  by 
adhesions.  They  occasionally  lead  to  stenosis.  This  is  due  (a)  to  cicatricial  con- 
traction (see  Fig.  624),  and  (b)  to  granuloma  occlusion  (see  Fig.  623). 

Fenwick  and  DodwelP  give  the  following  table  of  frequencies  of  intestinal  tuber- 
culosis, founded  on  2000  necropsies  at 
the  Brompton  Hospital  for  Consump- 
tion and  Diseases  of  the  Chest: 

Ileocecal  region 85.0  per  cent. 

Ascending  colon  .  .  .  .51.4 
Transverse  colon.  .  .  .30.6 

Jejunum 28.0 

Rectum 14.0 

Sigmoid 13.5 

Duodenum   3.4 

Anthrax. — In  the  intestinal  form 
there  is  hemorrhage  into  the  stomach 
and  bowels.  In  Poelchen's^  case  of  five 
days'  standing  there  were  no  gastro-in- 
testinal  symptoms.  The  spleen  was  en- 
larged, the  stomach  and  intestines  both 
contained  ulcers. 

Ulcers  from  Burns. — We  owe  our 
knowledge  of  this  variety  to  Curling,^ 
of  England,  who  found  it  present  in  six- 
teen of  one  hundred  and   twenty-five 
necropsies,  and  more  often  in  young  in- 
dividuals.    In  one  of  his  cases  a  branch 
of  the  pancreatico-duodenal  artery  was 
eroded  and  caused  death.     Perry  and 
Shaw*  found  it  five  times  in  one  hun- 
dred and  forty-nine  necropsies  follow- 
ing burns. 
It  is  supposed  to  be  due  to  toxins  produced  in   the  burned  area  and  excreted 
through  the  bile.     Kijanitzin^  claims  to  have  isolated  a  toxic  substance  from  the 
blood  after  burns.     These  ulcers  develop  in  from  seven  to  fourteen  days,  but  never 
in  the  stomach.     A  similar  variety  of  ulcer  has  been  known  to  follow  frost-bite. 

^Fenwick  and  Dodwell:  "Perforation  of  the  Intestine  in  Phthisis,"  London  Lancet,  1892, 
ii,  133. 

^  Poelchen,  Richard:  "Ueber  die  Aetiologie  der  stricturirenden  Mastdarmgeschwiire," 
Virchow's  Archiv,  1892,  cxxvii,  189. 

^  Curling,  T.  B.:  "On  Acute  Ulceration  of  the  Duodenum,"  Med.  Chir.  Trans.  London,  1842, 
XXV,  260. 

*  Perry  and  Shaw:  Loc.  cit. 

^  Kijanitzin,  J.:  "Zur  Frage  nach  der  LTrsache  des  Todes  bei  ausgedehnten  Hautverbren- 
nungen,"  Virchow's  Archiv,  1893,  cxxxi,  436. 


Fig.  624. — Tuberculosis  of  Cecum  (Cullen). 

a,  Stricture  and  shot;  b,  distal  end;  c,  proximal  end;  d, 

ileocecal  valve. 


INFECTIVE    GRANULOMATA.  425 

Embolism  and  Thrombosis. — This  variety  is  unusual;  it  is  found  principally 
in  the  small  intestine  and  is  very  rare  beyond  the  ileocecal  valve.  It  is  always  due  to 
circulatory  disturbances,  as  occlusion  of  the  smaller  branches  of  the  mesenteric 
vessels  as  a  result  of  atheroma,  endocarditis,  phlebitis,  etc.  The  ulcers  are  small  in 
size,  as  a  rule,  round  or  irregular;  occasionally  they  encircle  the  bowel. 

Uremia. — Duodenal  ulcer  was  found  in  twelve  out  of  seventy  deaths  from  uremia 
in  Bright's  disease.  The  ulcer  is  due  to  the  irritating  effect  of  the  retained  urea,  or, 
in  its  splitting  off,  to  the  carbonate  of  ammonia. 

Toxic. — These,  ulcers  result  from  poisoning  from  phosphorus,  arsenic,  and 
mercury. 

Miscellaneous. — Occasionally  ulcers  are  found  in  pemphigus,  erysipelas,  leprosy, 
septicemia,  gout,  scurvy,  leukemia,  amyloid  disease;  also  after  acute  infectious 
diseases — yellow  fever,  diphtheria,  smallpox,  etc. 

Symptoms. — There  are  no  distinctive  symptoms  for  these  different  varieties. 
The  general  symptoms  are :  (1)  Diarrhea.  (2)  Blood,  pus,  or  shreds  of  tissue  in  the 
feces,  especially  if  in  the  large  intestine.  (3)  Pain.  This  may  be  absent;  accord- 
ing to  Nothnagel,^  the  absence  of  pain  may  be  due  to  two  causes — destruction  of  the 
nerves  by  the  disease  process,  or  the  continual  irritation  may  have  exhausted  the 
sensitiveness.  (4)  Presence  of  tubercle  bacilli  in  the  feces.  Dyspepsia  and  vomit- 
ing are  rare.     (5)  The  presence  of  intestinal  worms  or  eggs  in  the  feces. 

The  chief  symptom  in  the  tuberculous  variety  is  diarrhea,  and  when  associated 
with  hemorrhage  has  the  following  syndrome:  elevation  of  temperature  (usually 
103°  to  105°),  pain,  nausea  and  vomiting,  local  abdominal  sensitiveness,  and 
macroscopic  appearance  of  blood  in  the  stool  the  following  day. 

INFECTIVE  GRANULOMATA. 

(Tuberculosis  is  treated  of  elsewhere  in  the  present  work.) 

Actinomycosis. — This  usually  develops  in  the  large  intestine.  Its  frequency 
may  be  judged  from  the  four  hundred  and  twenty-one  cases  collected  by  Illich^: 
51.8  per  cent.,  neck;  13.8  per  cent.,  lungs;  21  per  cent.,  abdomen  (mostly  in- 
testinal);   2.6  per  cent.,  skin;    7  per  cent.,  undetermined. 

The  organisms  may  form  a  thin  growth  along  the  mucous  surface  of  the  bowel, 
or  the  wall  throughout  may  be  invaded.  The  process  inay  perforate  into  the  rectum 
or  the  bladder.  Lanz^  has  set  aside  the  actinomycosis  of  the  vermiform  appendix 
as  a  special  variety — perityphlitis  actinomycotica — comprising  about  one-half  of  the 
total  number  of  cases  of  intestinal  actinomycosis.  It  will  be  diagnosed  as  appendi- 
citis until  examined  by  the  microscopist  as  to  its  true  nature. 

The  symptoms  are  not  very  characteristic — attacks  of  colic,  vomiting,  and  con- 
stipation alternating  with  diarrhea.     In  the  cecal  variety  there  is  a  perceptible 

1  Nothnagel,  H.:   "Diseases  of  the  Intestines  and  Peritoneum,"  Phila.,  1907. 
^  lUich,  A.:    Beitrag  zur  Klinik  der  Aktinomykose,  Wien,  1892. 

^  Lanz,  Otto:  "Ueber  crurale  Blasenhernie,"  Correspondenz-Blatt.  f.  Schweizer  Aerzte, 
1892,  xxii,  709. 


426 


INTESTINAL    SURGERY, 


swelling.  The  feces  should  be  carefully  examined  from  day  to  day  for  the  actinomy- 
ces  to  establish  the  differential  diagnosis. 

In  a  case  operated  on  by  the  writer  several  years  ago  the  patient  had  severe  pains 
in  the  abdomen,  and  frequent  vomiting,  but  no  diarrhea.  The  pain  and  vomiting- 
continued  for  five  days,  when  the  latter  subsided,  but  there  remained  considerable 
tenderness  in  the  upper  abdomen  with  extensive  induration  over  the  chest  margin. 
A  rib  was  resected  and  a  subcostal  abscess  cavity  drained;  the  patient  gradually 
sank,  and  died  ten  days  after  the  operation. 

Necropsy  showed  an  abscess  cavity  running  through  the  diaphragm  on  the  left 
side.  There  was  an  opening  1  inch  long  through  the  great  omentum  between  the 
transverse  colon  and  stomach,  extending  down  into  another  abscess  caAity. 


Fig.  625. — Ixtussusception  Caused  by  Fibroid  Tumor  of  the  Intestine  (Hunner's  case;  drawn  from  speci- 

men),      (f  Natural  size. ) 
/,  Fibroid  tumor  causing  intussusception;  b,  line  of  intestinal  invagination;  c,  intussuscipiens;  d,  intussusceptum. 


The  omentum  around  this  cavity  was  densely,  and  over  its  entire  surface  more 
sparingly,  studded  with  pale  yellow  flakes  about  ^  inch  in  diameter,  much  resembling 
flattened  grains  of  wheat  or  the  plaques  of  pancreatic  fat  necrosis.  The  fatty  tissues 
attached  to  the  colon  and  its  mesentery  were  considerably  infiltrated  with  similar 
bodies.  The  spleen  was  found  floating  in  the  cavity,  supported  only  by  its  vessels, 
and  showed  no  signs  of  infection. 

On  examining  the  surface  of  the  stomach  and  bowels  the  writer  was  unable  to 
find  an  abrasion  through  which  the  fungus  had  escaped  from  the  alimentary  canal. 
Judging  from  the  point  at  which  the  greatest  destruction  had  occurred,  it  would 
appear  that  the  germs  had  escaped  through  the  walls  of  the  stomach  or  duodenum. 

Treatment. — The  abscesses  should  be  drained  as  rapidly  as  they  form.  lodid 
of  potash  should  be  given  in  a  systematic  manner  and  the  x-ray  treatment  pushed  to  a 


TUMORS.  427 

maximum  of  toleration.  When  the  disease  is  confined  to  the  appendix  or  to  a  seg- 
ment of  the  bowel  without  perforating  its  wall,  a  resection  should  be  made  extending 
far  beyond  the  infiltrated  margin. 

Syphilis  is  rare  in  the  small  intestine;  it  attacks  principally  the  large  intestine, 
colon  and  lower  rectum.  Ulcers  are  caused,  as  a  rule,  by  the  breaking  down  of 
tertiary  deposits.  Perforation  into  the  neighboring  viscera  is  common,  but  an  open- 
ing into  the  peritoneum  is  apparently  unknown. 

Syphilis  is  attended  by  an  obstinate  diarrhea,  which  may  last  for  years  unless 
combated  by  specifics.  (The  surgical  treatment  of  specific  lesions  of  the  rectum  is 
considered  under  a  separate  head.) 


TUMORS. 

Benign  tumors  comprise  adenoma,  lipoma,  fibroma,  myoma,  and  angioma. 

Of  these  varieties,  adenomata  are  probably  the  most  common.  They  may  occur 
in  any  part  of  the  intestines,  but  are  especially  frequent  in  the  rectum.  They  are 
generally  multiple,  as  many  as  10,000  having  been  counted  in  a  single  case  (Luschka^). 
They  may  become  cancerous. 

Lipomamay  be  single  or  multiple;  they  are  not  common.  •  They  sometimes  grow 
from  the  appendices  epiploica:;  of  the  colon. 

Fibroma  and  fibromyoma  are  very  rare  They  produce  symptoms  of  obstruction 
by  their  size  and  cause  intussusception  by  traction  at  point  of  attachment  (Fig.  625). 

Myoma  are  submucous  or  subserous  and  occur  with  about  equal  frequency, 
though  the  former  do  not  grow  as  large  as  the  subserous  type.  Both  varieties  are 
more  frequent  in  the  large  bowel.  AUchin  and  Hebb^  report  a  rare  case  of  lymphan- 
giectasis  of  the  intestine.  The  mucosa  of  the  entire  small  intestine  was  beset  with 
myriads  of  whitish  flocculi,  not  extending  into  the  mucosa  proper;  no  ulcers  were 
found.  The  process  was  strictly  limited  to  the  small  intestine;  the  stomach  and 
large  intestine  were  free.  The  patient  was  a  man  of  thirty-eight  with  a  history  of 
diarrhea  for  some  months  before  admission. 

The  symptoms  of  these  benign  tumors  are  few  unless  they  produce  obstruction  or 
cause  invagination.  If  multiple,  they  may  give  rise  to  hemorrhage  and  catarrhal 
enteritis.  The  growths  are  either  sessile  or  pedunculated;  if  the  latter,  they  appear 
as  "polypi,"  which  sometimes  tear  loose  or  slough  off.  Occasionally  they  reach  such 
a  size  that  they  are  palpable  through  the  abdominal  wall. 

The  treatment  will,  as  a  rule,  be  that  of  obstruction  caused  by  them,  with  excision 
of  the  segment  of  bowel  containing  the  tumor. 

Malignant  Growths. — Carcinoma  of  the  small  intestine  is  rare  compared  with 
that  of  the  large.     It  is  nearly  always  primary;   secondary  growths  are  uncommon. 

^  Luschka,  H.:  "Ueber  polypose  Vegetationen  der  gesammten  Dickdarmschleimhaut," 
Virchow's  Archiv,  1861,  xx,  133. 

^Allchin  and  Hebb:  "  Lymphangiectasis  Intestini,"  Trans.  Path.  Soc.  of  London,  1894-95, 
xlvi,  p.  221. 


428 


INTESTINAL    SURGERY, 


Pyloric  cancer  occasionally  extends  to  the  duodenum.  (See  Tumors  of  the 
Rectum.) 

Sarcoma  of  the  intestine  is  not  so  common  as  carcinoma.  In  the  small  intestine 
it  is  usually  high  up,  the  tendency  to  carcinoma  becoming  more  marked  as  the  cecum 
is  approached.  In  a  case  reported  by  LaRoy  1250  melanosarcomata  were  discov- 
ered. Nearly  twice  as  many  men  as  women  are  affected,  and,  as  in  sarcoma 
elsewhere,  the  ages  average  less  than  in  cancer. 

The  symptoms  are  few:  palpable  tumor;  frequent  elevation  of  temperature, 
which  confounds  it  T\'ith  granuloma;  rapid  emaciation,  since  sarcoma  grows  faster 
than  carcinoma;  and  occasionally  blood  in  the  stools.     Stenosis  is  rare;  on  the  con- 


FlG.    626. EXLARGEMEXT    OF    IxTESTIXAL    LuMEX    BT    SaRCOMA. 

a,  Lumen;  b,   thick  bowel  wall:   c,  proximal  end;   d,  distal  end. 


trary,  there  is  usually  a  considerable  dilatation  at  the  site  of  the  tumor,  as  the  sar- 
coma involves  the  muscular  and  fibrous  layers  and  not  the  mucous. 

It  many  times  follows  a  mild  trauma,  and  must  be  carefully  differentiated  from 
gumma,  which  it  closely  resembles  clinically  and  macroscopically.  The  specific 
treatment  is  the  best  pre-operative  diagnostic  test. 

Treatment  is  operative  only,  though  the  results  are  not  very  encouraging,  the 
mortality  being  26  per  cent.,  which  is^somewhat  due  to  the  fact  that  the  patients  do 
not  apply  to  the  surgeon  early  enough. 

Carcinoma  is  rarely  ever  found  in  the  ileum  or  jejunum.  It  occurs  in  the  large 
intestine  most  frequently  at  its  strictures  or  flexures,  as  these  points  are  subjected 
to  mild  traumas  by  fecal  stasis  and  excessive  contractions.  They  occur  in  the  follow- 
ing order  of  frequency:  rectum,  sigmoid,  cecum,  appendix,  hepatic  flexure,  splenic 
flexure,  etc. 

Early  operative    treatment    should    be   resorted    to    as    described   fully  under 


INTESTINAL    REPAIR. 


429 


teclinic.     The  permanent  results  are  fairly  good,  as  metastasis  is  late,  these  struc- 
tures having  only  a  sparse  lymphatic  supply. 

INTESTINAL  REPAIR. 
Operations  for  intestinal  repair  are  performed  for: 

1.  Injuries  and  perforations,  not  involving  the  mesenteric  attachment,  with 

destruction  of  less  than  one-third 
of  the  circumference. 

2.  Injuries  at  the  mesenteric 
attachment. 


Fig.  627. — Intestinal  Sutures. 
A,  Lembert  suture;   B,   Czerny-Lembert  suture. 


Fig.  628. — Wolfler's  Double  Row  of  In- 
terrupted Sutures. 


3.  Disease  or  extensive  injury,  necessitating  resection  of  the  bowel. 
These  lesions  are  repaired  by:    (a)  Suture,  either  longitudinal  or  transverse; 
(h)  resection  with  end-to-end,  side-to-side,  or  end-to-side  anastomosis. 


Fig.  629. — Cushing's  Method  of  Insertion  of  Lembert's  Type  of  Suture, 


430 


INTESTINAL    SURGERY. 


Lembert^  occupies  a  very  prominent  place  in  the  history  of  intestinal  repair,  as 
his  suture  is  the  foundation  of  the  best  type  of  intestinal  approximation.  His  idea  of 
apposition  of  serous  surfaces  for  the  purpose  of  producing  permanent  adhesions  in- 
augurated a  new  era  in  this  branch  of  surgery.  Czerny's^  modification  was  an  im- 
portant step  in  advance — the  approximation  of  the  serous  surfaces  being  supple- 
mented by  that  of  the  mucous  edges  (Czerny-Lembert  suture). 


Fig.  630. — Dupuytren's  Suture,  Lembert  Type. 


Fig.   631. — Dupuytren's   Intestinal  Suture,   with 
Seconij  Row  of  Sutures. 


Fig.  632.— Connei.l  Suture. 
Method  of  applying  stitch  in  mesenteric  border 

Intestinal  approximation  may  be  made  by:    (a)  Suture  alone;    (h)  suture  with 
mechanical  aids;    (c)  mechanical  aids  only. 

Sutures. — The  best  known  and  most  rehable  sutures  are  the  following,  and  no 
detailed  description  is  necessary,  since  the  illustrations  furnish  sufficient  information. 

The  Lembert  is  a  suture  which  passes  through  the  two  outer  coats  of  the  bowel, 
so  as  to  approximate  the  serous  surfaces  and  invert  the  cut  edges  (Fig.  627). 
1  Lembert,  J.  B.:   "Rep.  Gen.  d'Anat.  et.  de  Phy.  Path.,"  1826,  ii,  3. 


INTESTINAL   REPAIR. 


431 


The  Czerny-Lemhert  is  a  double-row  suture;  the  first  (Czerny)  or  deep  series  in- 
cludes all  the  coats  of  the  bowel;  the  second  (the  Lembert),  described  above,  should 
be  placed  just  outside  and  close  to  the  Czerny  so  as  to  form  only  a  small  inversion 
diaphragm  (Fig.  627). 

The  Wolfler  is  a  double  row  of  interrupted  sutures  (Fig.  628). 
The  Hoisted}  is  of  the  Lembert  type;   in  other  words,  it  is  a  plain  quilt  suture 
passing  through  the  two  outer  coats  and  some  of  the  inner. 

The  Cushing^  (Fig.  629)  is  also  a  continuous  suture  of  the  Lembert  type. 

The  Dupuytren^  (Fig.  630,  631)  is 
another  continuous  suture  of  the  Lem- 
bert type. 

The  Con7ieU*  (Figs.  632,  633,  634,  635, 
636)  passes  through  all  the  coats,  and  the 


Fig.  633. — Connell's  SuTLiRE. 

Knots  applied  within  the  lumen  of  bowel;    starting 

the  second  row. 


Fig.  634. — Connell's  Suture. 
Method  of  inserting  needle  for  tying  the  last  knot. 


knots  when  tied  are  within  the  lumen.     When  understood,  this  is  easily  applicable 
and  very  effective. 

Of  all  these  methods,  the  Czerny-Lembert  is  the  most  practical  and  easily  under- 
stood. The  errors  in  its  application  are:  (1)  Failure  to  include  the  vessels  in  the 
edges  of  the  incision  and  to  forcibly  compress  them;    (2)  the  penetration  of  the 

1  Halsted,  W.  S.:   "Intestinal  Anastomosis,"  Johns  Hopkins  Hosp.  Bull.,  1891,  ii,  1. 

2  Gushing,  H.  W.:  "The  'Right  Angle'  Continuous  Intestinal  Suture,"  Med.  and  Surg.  Rep., 
Boston  City  Hosp.,  1889,  81. 

2  Dupuytren,  G.:    "Lecons  Orales  de  Clinique  Chirurgicale,"  Paris,  18.32-4. 
^Connell,  F.  G.:     "The  Knot  within  the  Lumen  in  Intestinal   Surgery,"  Jour.  Amer.  Med. 
Assoc,  1901,  xxxvii,  2,  952. 


432 


INTESTINAL   SURGERY. 


mucosa  by  the  needle;  (3)  failure  to  accurately  approximate  the  peritoneum  at  the 
mesenteric  attachment,  thus  preventing  infection  by  leakage;  this  is  the  most 
vulnerable  point  in  all  these  methods  of  approximation ;  an  overstitch  should  be  taken 
in  the  mesentery  at  its  attachment  to  the  intestine  so  as  to  overlap  the  divided 
peritoneal  edges;  (4)  the  occasional  insertion  of  the  Lembert  portion  too  far  from 
the  Czerny  portion,  thus  inverting  the  bowel  in  the  form  of  a  diaphragm,  which  tends 
to  contract  and  ultimately  to  produce  obstruction;    (5)   the  infection  along  the 

Czerny  line  of  approximation  leading  to  failure. 
^^?-^  of  union  and  secondary  leakage  (this,  however, 

is  not  as  frequent  as  is  generally  supposed) ;  (6) 
the  use  of  unabsorbable  material  for  the  Czerny 
portion  gives  rise  to  the  production  of  much 
-.^  cicatricial  tissue,  which  tends  to  contraction  and 

stenosis;  if  absorbable,  it  gives  support  for  a 
couple  of  hours  and  no  longer;  (7)  the  infection 
at  the  mesenteric  attachment  or  some  other  por- 
tion of  the  circumference,  when  virulent,  tends 
to  separation  of  the  approximated  edges;  super- 
ficially placed  sutures  also  permit  leakage;  this 


Fig.  635. — Conneli.'s  Sutuee. 

Thread  drawn  transversely  across,  ready  for 

tying. 


Fig.  636. — Connell's  Suture. 
Latter  tied  and  ready  for  embedding. 


separation  is  many  times  erroneously  attributed  to  the  type  of  suture  or  method 
employed  for  the  approximation. 

The  suture  material  should  be  of  silk  or  linen,  preferably  the  celluloid-linen 
(Pagenstecher).  An  absorbable  suture  should  never  be  relied  on  for  union  of  the 
intestine.  Intestinal  sutures  are  safer  when  there  is  no  capillarity;  hence,  if 
silk  is  used  it  should  be  twisted  and  coated  with  wax,  rubber,  or  paraffin  to 
destroy  its  capillary  action.  This  material  is  not  so  effective,  however,  as  the 
celluloid. 

When  more  than  one-third  of  the  bowel  circumference  is  involved  and  resection 
not  indicated,  it  is  better  to  make  an  elbow  approximation,  as  a  larger  lumen  will 
be  thereby  obtained.     This  V-shaped  kinking   (Fig.   637)  gradually  assumes  a 


INTESTINAL   REPAIR. 


433 


straight  position.     The  elbow  approximation  is  not  permissible  where  the  mesentery 
has  been  sacrificed,  as  a  gangrene  of  the  convex  portion  would  result. 


\ 


Fig.    638. — Senn's    Bone   Plate    with 
Threads  Ready  for  Insertion. 


Fig.  637. — Method  op  Enlarging   Bowel  Where  Constric- 
tion Exists  Between  a  and  c. 
Latter  points  are  approximated,  so  as  to  enlarge  lumen  by  elbow- 
ing process. 


Fig.    639. — Coffey's    Crushable    Potato 
Bobbin. 


Sutures  and  Mechanical  Aids. — Among  the  mechanical  aids  which  have  been 
used  in  approximation  may  be  mentioned:  Senn's^  decalcified  bone  plates  (Fig.  638) 


Fig.  640. — Method  of  Insertion  of  Suture  with  Robson's  Bobbin  as  a  Mechanical  Aid. 


Landerer's  potato  bobbin,  Coffey's  crushable  bobbin  (Fig.  639),  Mayo  Robson's' 

1  Senn,  N.:  Ann.  Surg.,  St.  Louis,  1888,  vol.  vii,  p.  1. 

2  Robson,  A.  W.  Mayo:    "A  Method  of  Performing  Intestinal  Anastomosis  by  Means  of 
Decalcified  Bone  Bobbins,"  Brit.  Med.  Jour.,  1893,  i,  688. 

VOL.  11—28 


434 


INTESTINAL   SURGERY. 


bone  bobbin  (Fig.  640),  Allingham's  bone  bobbin,  Harrington's^  segmented  ring, 
Dawbarn's  potato  plates  (Figs.  641  and  642),  Murphy's^  button  and  its  modifica- 
tions, such  as  those  of  Hartmann, 
Kiimmell,  Jaboulay,  Frank,  etc. 
All  of  these  are  so  well  under- 


stood that  it  is  unnecessary  to  give 
a  detailed  description  of  their  ap- 
plication. 

In  anastomosis  by  mechanical 
means  we  have  to  consider  the 
end-to-end  anastomosis,  then  the 
end-to-side,  and  lastly  the  side-to- 
side. 

Approximation  with  the 
Murphy   Button. — Neither   the 

Fig.  641.— Dawbarn's  Potato  Plate  with  Suture  Inserted.         buttOU,      itS       modifications,      UOr 

suture   should    ever   l^e    used   in 
end-to-end  anastomosis  of  the  large  intestine  (except  in  the  rectum  or  sigmoid)  where 


Fig.   642. — Technic   of   Lateral  Anastomosis   by  Dawbarn's  Potato  Plate. 
Same  in  position.     Curved  bistoury  executing  division  of  clamp  septum. 

an  end-to-side  or  side-to-side  anastomosis  is  possible,  as  anatomically  too  large  an 
area  of  the  bowel  circumference  is  uncovered  by  peritoneum. 

'  Harrington,  F.  B.:  "Segmented  Ring  for  Intestinal  Anastomosis,"  Boston  Med.  and  Surg. 
Jour.,  1902,  cxlvii,  52 L 

^Murphy,  J.  B.:  "Cholecysto-intestinal,  Gastro-intestinal,  Entero-intestinal  Anastomosis, 
etc.,"  N.  Y.  Med.  Record,  1892,  xlii,  667. 


INTESTINAL   REPAIR. 


435 


Technic  for  Resection  and  End-to-end  Anastomosis  by  the  Alurphy  Button. — 
The  special  instruments  necessary  are: 

Round  button  No.  3. 

Intestinal  clamps  or  forceps  (Murphy's  intestinal  clamp  (Fig.  648),  LaPlace's 
or  O'Hara's^  forceps). 

Aneurism  needle. 

Hartmann's  lateral  button-holder  or  Cordier's^  obturator. 

Most  of  these  instruments  are  well  known  to  every  surgeon,  except  possibly 
the  button-holder.  .  This,  as  shown  in  the  illustration 
(Fig.  644)  j  is  composed  of  two  long  blades  joined  like 
an  ordinary  hemostat,  the  ends  of  which  terminate  in 
flat  semilunar  segments  with  which  to  grasp  the  cylin- 
ders of  the  button.  I  have  used  these  forceps  for  the 
past  fifteen  years,  and  found  them  very  serviceable, 
giving  full  control  of  the  button  imtil  the  two  halves 
are  securely  invaginated. 

The  first  step  (a)  is  to  protect  the  rest  of  the 
viscera  from  the  coil  of  intestine  which  is  to  be  pre- 
pared for  resection.  This  coil  is  freed  from  its 
contents  by  pressure,  not  severe  enough,  however, 
to  injure  the  wall  of  the  bowel;  (b)  then  one  of  the 


L__^ — ^  "-^^^^i: 


Fig.  643. — Technic  or  Lateral  Anastomosis. 
Appearance  of  puckering-string  in  lateral  anastomosis. 


Fig.  644. — Hartmann's  Button- 
holder. 


intestinal  clamps  or  forceps  is  applied  to  the  intestine  both  proximal  and  distal  to  the 
area  to  be  resected,  (c)  LaPlace's  forceps  is  very  useful,  though  for  some  years 
past  the  writer  has  used  Murphy's  intestinal  clamp,  as  its  simplicity  renders  it 
readily  serviceable,  (d)  An  aneurism  needle  threaded  with  catgut,  silk,  or  linen 
is  passed  through  the  mesentery  tributary  to  the  zone  to  be  resected,  1^  inches  from 
the  intestinal  border;    care  should  be  taken  not  to  include  more  of  the  mesentery 

^  O'Hara,  M.:  "A  Method  of  Performing  Anastomosis  of  Hollow  Viscera  by  a  New  Instru- 
ment," Ann.  Surg.,  1901,  xxxiii.  179. 

^  Cordier,  A.  H.:  "Murphy  Button  Obturator  and  Applicator,"  Jour.  Amer.  Med.  Assoc, 
1905,  xlv,  2,  853. 


436 


INTESTINAL   SURGERY. 


than  is  complementary  to  the  area  to  be  excised,  (e)  The  mesentery  should  be 
split  centrifugally  from  the  ligature  to  the  intestinal  border,  then  two  floss  needles 
2^  inches  long,  threaded  with  silk  or  linen  16  inches  long,  are  used  to  run  the  pucker- 
ing-string.  The  initial  over-stitch  is  made  in  the  mesenteric  border;  the  needles 
are  then  run  in  and  out  through  the  wall  on  each  side  of  the  intestine  in  the  Kne  of 
intended  division  to  its  convex  border  (Fig.  648).  Retaining  these  needles  in  the 
wall  as  splints,  the  intestine  is  divided  with  a  scissors  close  to  the  needles — thus 
avoiding  the  possibility  of  cutting  the  threads.  The  needles  are  then  drawn  through 
(Fig.  649),  the  button  inserted  (Fig.  649),  and  the  puckering-string  tied  close  to  its 

cylinder,  care  being  taken  to  invert  the  mucosa. 
The  thread  is  then  divided  close  to  the  knot.  The 
other  half  of  the  button  is  inserted  in  the  same 


Fig.  645. — Lateral  Anastomosis  with  Murphy's  Oblong  Button. 
A,  Proximal  portion;   B,  closure  of  same;   C,  distal  portion;   D,  the  same  closed;   e,  e,  Hartmann's  button-holder 

attached  to  halves  of  button. 

manner  (Fig.  649)  and  Hartmann's  clamps  placed  on  each  cylinder  to  facilitate 
their  approximation.  The  mesentery  is  then  divided  and  the  segment  removed; 
the  two  halves  of  the  button  are  then  pressed  slowly  but  forcibly  together.  (/)  The 
peritoneum  and  the  viscera  are  protected  from  the  contents  of  the  intestine  by  an 
assistant  detailed  for  this  purpose. 

The  supporting  suture  advocated  and  used  by  some  operators  is  entirely  super- 
fluous. The  lateral  and  end-to-end  approximations  are  made  in  the  same  manner; 
the  convex  portion  of  the  bowel  should  be  used  for  apposition. 

The  edges  of  the  button  exert  a  constant  pressure  on  the  intestinal  wall  until  the 
pressure  necrosis  has  reached  its  maximum  on  the  third  day.     The  approximating 


INTESTINAL   REPAIR. 


437 


edges  of  the  button  should  be  an  accurate  semicircle,  thus  bringing  the  point  of  great- 
est pressure  in  the  center  of  the  contact  zone,  and  furnishing  a  good  surface  for  union 
outside  of  the  center  line  of  pressure  necrosis.  In  the  selection  of  buttons  the  oper- 
ator should  note  the  uniform  semicircular  surface  of  the  cups  and  the  integrity  of  the 
spring  catches.  It  is  essential,  also,  that  the  margins  of  the  button  be  constructed 
so  as  not  to  compromise  the  blood-supply  of  the  bowel  edges.  The  schematic  draw- 
ing (Fig.  646)  shows  what  I  desire  to  emphasize.     (The  writer  will  not  give  a  detailed 

description  of  the  technic  of  insertion  of  sutures, 
as  the  cuts  sufficiently  illustrate  their  application.) 
In  end-to-end  approximation,  sepsis  and  sub- 
sequent separation  occur  most  frequently  at  the 
mesenteric  attachment.  The  explanation  for  this 
is  that  there  is  no  peritoneal  covering  at  this  point, 
consequently  primary  peritoneal  agglutination  can- 
not occur.  Secondly,  the  zone  here  is  exposed  to 
infection,  since  loose  connective  tissue  and  fat  are 


Fig.    646. — Murphy's    Oblong    Button 
AND  Key. 
The    profile    of     the    approximation 
surface  should  be  semicircular  (a)  instead 
of  being  flat. 


Fig.  647. — Showing   Manner  in  Which  Button  is  Introduced. 
a.  Ends  of  purse-string  suture,  ready  to  be  tied;  h,  forceps  hold- 
ing edge  of  button;   c,  forceps  everting  cut  edge  of  intestine  to  allow 
introduction  of  button. 


known  to  have  less  resistance  to  microbic  invasion  than  any  tissues  in  the  body. 
Lastly,  at  this  location  it  is  practically  impossible  to  secure  a  fiat  lateral  surface 
for  approximation. 

The  failure  may  be  the  result  of  infection  at  the  line  of  union,  either  from  pre- 
existing disease  or  from  pre-existing  infection,  from  infiltration  of  the  intestinal  wall 
above  the  point  of  obstruction,  or  fecal  retention. 

Septic  gangrene  or  ischemia  at  the  junction  may  also  cause  failure  of  union, 
which  may  result  from :  (a)  Removal  of  more  of  the  mesenteric  border  than  of  the 
convex  portion  of  the  wall,  (b)  Including  too  large  a  mass  of  vessels  in  the  suture, 
thus  shutting  off  the  blood-supply,  (c)  Insufficient  resection  of  the  infiltrated  area 
of  the  intestinal  wall,  especially  on  the  proximal  side  of  an  obstruction. 


438 


INTESTINAL   SURGERY. 


In  the  presence  of  obstruction  the  infikration  of  the  wall  is  so  great  that  the 
sHghtest  mechanical  disturbance  ^^^ll  produce  necrosis.  For  this  reason,  several 
inches  or  even  feet  of  the  mural  infiltration  should  be  resected  in  order  to  obtain  a 
good  sound  tissue  for  approximation.  ]Many  deaths  hitherto  attributed  to  the 
means  of  approximation  are  really  due  to  a  failure  to  observe  these  points.  Traction 
or  tension  will  also  endanger  the  line  of  union,  as  the  stitches  pull  out  or  cut  through 
and  permit  leakage.  Still  another  cause  of  failure  is  tuberculosis  of  the  peritoneum, 
which  retards  peritoneal  agglutination.  Hence  resection  of  the  intestine  in  the 
presence  of  tuberculous  peritonitis  is  always  hazardous. 

The  danger  from  all  these  causes  can  be  materially  lessened  by  protecting  the  Hne 
of  union  with  omental  flaps  or  grafts.  The  peritoneum  of  the  omentum  favors 
agglutination  and  is  a  source  of  great  protection  to  the  patient.  These  omental 
flaps  mil  not  only  protect  the  peritoneal  ca^'ity  from  subsequent  infection  from  the 


Fig.  648. — Techxic  of  Exd-to-exd  Anastomosis. 
a,   Intestinal  clamp   on   the   intestine;     b,    straight    needle    threaded   with   suture   intended    for   puckering 
suture;  c,  dotted  line  to  indicate  triangular  incision  in  mesentery;  d,  straight  needles  acting  as  splints  ready  to  be 
pulled  out. 

intestinal  canal,  but  will  increase  the  vascularization  of  the  line  of  union,  a  very 
important  and  essential  point.  If  the  line  of  union  is  well  nourished  the  process  of 
repair  has  all  the  guaranty  of  success  necessary. 

The  technic  of  omental  grafting  is  as  follows:  A  segment  of  omentum,  the  size 
and  shape  of  which  are  determined  by  the  surgeon,  is  excised  and  immediately 
placed  in  hot  (98.6°)  normal  salt  solution.  After  a  careful  scarification  has  been 
made  on  each  side  of  the  suture  line,  the  omental  graft  is  placed  on  a  piece  of  gauze 
to  dry,  and  is  then  applied  over  the  line  of  sutures  (care  being  taken  that  the  center 
of  the  graft  corresponds  to  the  suture  line),  and  is  fixed  to  the  bowel  by  fine  catgut 
sutures  (Fig.  650).  Firm  agglutination  between  the  graft  and  the  intestine  forms 
in  a  few  hours.  It  is  easier  to  apply  these  flaps  when  they  are  not  detached  from  the 
omentum,  but  are  slid  over. 

End-to-side  Approximation. — In  many  cases,  especially  when  enteric  exclusion 


INTESTINAL    REPAIR. 


439 


is  desired,  an  end-to-side  anastomosis  may  be  indicated.     This  may  be  accomplished 

either  with  suture  or  with  the  round  button   (Fig. 
647) ;  the  oblong  button  cannot  be  used.    This  variety 
\  \        of  approximation  offers  no  especial  difficulties  except 

when  segments  of  intestine  of  unequal  size  have  to  be 
united,  in  which  event  Maunsell's^  method  of  suture 
gives  very  good  results. 


\ 


\ 


Fig.  649. — End-to-end  Anastomosis  (Murphy's  method). 
a,  Intestinal  clamps  placed  on  the  intestine;  b,  forceps  grasping  the  edge  of  one  half;  c,  purse-string  suture  passed 
around  the  neck  of  the  button,  ready  to  be  tied. 

Side-to-side  Anastomosis. — This  variety  is  contraindicated  in  the  small  in- 
testine, except   where   the   ends   vary 


J 


greatly  in  size  or  where  the  INIaunsell 
method  is  difficult  or  impracticable. 
It  is  a  common  and  useful  way 
of  joining  the  small  to  the  large 
bowel.  It  is  the  most  favorable 
method,  so  far  as  .securing  immedi- 
ate union  is  concerned,  since  the 
entire  circumference  of  the  anasto- 
motic opening  is  surrounded  by  peri- 
toneum. The  local  irritation  will 
cause  a  rapid  formation  of  plastic 
exudate  over  the  fine  of  union,  and  in  this  way  the  latter  will  be  protected 


Fig.  650. — Omental  Graft.     Senn's  Method. 
Line  of  suture  covered  with  a  flap  of  omentum. 


jMore- 


'  Maunsell,  H.  W.:   "A  New  Method  of  Excising  the  Two  Upper  Portions  of  the_Rectum  and 
the  Lower  Segment  of  the  Sigmoid  Flexure  of  the  Colon,"  London  Lancet,  1892,  ii,  473. 


440 


INTESTINAL   SrRGERY. 


over,  the  sealing  of  the  suture-line  is  so  perfect  that  invasion  of  micro-organisms  is 
almost  impossible. 

Technic. — The  ends  are  closed  by  Czerny-Lembert  sutures,  or  by  crushing  them 
in  an  angiotribe,  and  after  removing  the  instrument  the  end  is  ligated  with  a  pucker- 
ing string  tied  in  the  crease  left  by  the  instrument  (Fig.  652).  The  mucosa  on  the 
distal  side  of  the  ligature  is  then  removed,  and  the  stump  embedded  as  in  appendec- 
tomy with  a  puckering  string  of  Lembert  sutures  (Fig.  653).  After  the  ends  are 
closed  the  sides  may  be  brought  together  with  double  rows  of  continued  sutures, 
using  stay-loops  at  either  end  of  the  line  of  union.  The  aperture  of  communication 
should  not  be  less  than  1  inch  nor  more  than  1^  inches.  It  was  feared  at  one  time 
that  the  hne  of  union  would  contract  and  produce  stenosis;    experience,  however, 

has  shown  this  rarely 
happens. 

As   in    end-to-end 
'-XXI^lnl    fWK^^^^^       I  approximation,        the 

bowel  should  be  care- 
fully clamped  to  ex- 
clude the  feces  from 
the  field  of  operation. 
If  the  button  is  used, 
the  oblong  one  should 
be  chosen.  Two 
straight  needles 


threaded  with  linen 
are  passed  through  the 
wall  of  each  segment 
of  bowel.  As  soon  as 
the  needles  are  in 
place  the  bowel  wall  is 
incised  between  them. 


Fig.    651. — Technic    in    End-to-side    Anastomosis    by    Murphy's    Round 

Button. 


a,  Cecum;   b,   button. 


It  has  always  been  my 
practice  to  make  this 
incision  while  the 
needles  are  still  in  place,  as  they  serve  as  sphnts  and  faciUtate  the  cutting,  after 
which  the  needles  are  drawn  through.  ^Vhen  this  is  accomplished,  the  halves  of 
the  button  are  inserted,  the  hgatures  tied,  Hartmann's  holders  appHed  on  the 
cylinders,  and  the  button  pressed  together.  The  bowel  must  be  so  connected  that 
the  peristaltic  waves  of  the  proximal  and  distal  segments  are  in  the  same  direction. 
The  use  of  the  button  shortens  the  time  of  the  operation  and  furnishes  a  uniform 
line  of  approximation.  When  the  pressure  necrosis  is  complete,  which,  as  stated 
above,  occurs  on  the  third  day,  we  have  similar  histologic  structures  in  edge-to-edge 
apposition,  which  is  ideal,  as  a  union  of  similar  histologic  structures  requires  the 
least  amount  of  connective  tissue  fthe  least  scar  tissue).     It  is  a  little  out  of  fashion 


INTESTINAL    REPAIR. 


441 


Fig.  652. — Technic  of  Lateral  Anastomosis. 

a,  Depression  produced  by  angiotribe;  b,  point 

of  ligation. 


now  to  admit  that  mechanic  aids  are  of  material  assistance  in  intestinal  approxima- 
tion, but  all  one  has  to  do  to  convince  himself  of  the  serviceable  purpose  of  these  aids 
to  suture,  is  to  visit  a  number  of  operating 
rooms  and  observe  the  irregularity  and  imper- 
fection of  suture  approximations  even  in  skilled 
hands.  The  results  in  Czerny's  clinic  show 
that  failures  attributed  to  various  sutures,  as 
those  of  Moynihan,  Gushing,  Connell,  !Mayo, 
or  to  the  button  are  due  not  so  much  to  the 
use  of  one  or  the  other  method,  as  to  their  in- 
accurate application,  the  failure  to  recognize 
pathologic  conditions  inimical  to  their  appli- 
cation or  to  regional  infection  during  the 
operation.  No  man  can  perform  well  an  in- 
testinal approximation  by  any  method  without 
first  familiarizing  himself  with  its  detailed 
technic  in  practical  application.  There  is  no 
method  too  simple  for  the  conscientious 
operator. 

Objection  has  been  made  (1)  by  some  who  have  had  little  or  no  experience  with 
mechanical  aids,  and  (2)  by  those  who  have  had  Htde  experience  with  any  technic 

of  intestinal  approximation;  their  opinions  should 
therefore  have  but  little  weight.  A  large  percentage 
of  expert  operators  make  use  of  the  button  in  compli- 
cated cases,  and  it  forms  a  ubiquitous  part  of  their 
armamentarium.  This  W2  interpret  as  meaning  that 
its  apphcation  is  easier  and  more  readily  accompHshed 
than  the  suture.  For  the  occasional  operator  and 
those  of  httle  experience  it  is  by  far  the  simplest  and 
safest  method  of  approximation.  The  conscientious 
critic  of  technic  and  methods  is  searching  for  a  means 
of  obtaining  ideal  results  under  diverse  and  uncon- 
trollable  pathologic  conditions.  Kocher,  the  tech- 
nical artist  of  the  profession,  remarks:  "1  use  the 
button  for  lateral  approximation  because  it  is  so 
simple." 

Approximation  of  the  Intestine  in  Fixed  Zones. 
— This  may   require   the   application   of   any  of  the 
methods  heretofore  described.     Hence    the   surgeon 
must  be  familiar  with  all  of  them,  as  the  occasions  for 
their  application  occur  at  times  most  inopportune  for  securing  information. 

The  danger  of  post-operative  stenosis  depends  on:    (1)  Segment  of  intestine  in- 
volved;  (2)  amount  of  connective  tissue  excited  by  the  union. 


s.-? 


Fig.    653. — Technic    op    Lateral 
Anastomosis. 
a,    Method     of    overstretching 
mesentery;    b,    Lembert    puckering 
stitch  invaginating  stump. 


442  INTESTINAL   SURGERY. 

The  greatest  tendency  to  stenosis  is  in  the  rectum,  next  in  the  sigmoid;  the  least 
in  the  jejunum,  next  in  the  ileum;  the  first  is  a  fixed,  the  second  a  movable  organ. 
Unused  artificial  communications  have  a  tendency  to  contract,  but  rarely  to  the 
extent  of  closure.  The  idea  that  a  complete  closure  of  unnecessary  anastomotic 
openings  by  restoration  of  normal  tracts  would  take  place,  has  been  disproved  by  an 
overwhelming  number  of  recent  observations;  i.  e.,  if  complete  closure  occurs,  it  is 
due  to  other  etiologic  factors  than  disuse. 

The  extent  of  intestine  resected  that  is  compatible  with  health  and  life  may  be 
estimated  from  the  following  cases:  Trzebicky^  has  collected  nine  cases  of  extensive 
resection  in  man  varying  from  39^  to  89  inches.  Of  these  cases,  five  recovered,  in- 
cluding Kocher's  case,  in  which  82|-  inches  were  resected,  and  Koeberle's^  of  81 
inches.  J.  F.  INIitchell,  of  the  Johns  Hopkins  Hospital,  resected  9  feet  of  bowel  for 
embohsm  of  the  mesenteric  artery.  H.  R.  Morton,^  of  Riverside,  Cal.,  resected  10 
feet  6  inches  of  the  small  intestine  for  a  myxosarcoma;  the  patient  recovered.  V. 
Pauchet*  removed  13  feet  of  small  intestine  and  the  patient  recovered. 

Enteric  Exclusion. — By  this  we  mean  the  exclusion  of  a  segment  of  the  intestine 
from  the  fecal  circuit,  though  the  segment  itself  is  not  removed  from  the  abdominal 
cavity.     Enteric  exclusion  may  be  either  partial  (unilateral)  or  complete  (bilateral). 

Resection  of  the  intestine  is  more  dangerous  than  exclusion.  If  the  bowel 
contents  penetrate  the  lumen  of  a  coil  closed  at  one  end  only,  the  peristaltic  and 
antiperistaltic  movements  force  them  back  into  the  rest  of  the  canal.  If  the  ex- 
cluded segment  is  again  reinstated  to  the  fecal  tract,  its  function  and  size  are  re- 
stored; otherwise  it  undergoes  atrophy. 

Partial  or  Unilateral  Enteric  Exclusion, — This  is  accomplished  by  dividing 
the  intestine,  closing  up  the  proximal  portion  of  the  distal  end,  and  implanting  the 
distal  end  of  the  proximal  portion  into  the  intestine  below  the  point  of  disease  or 
fistula.  Occasionally,  feces  regurgitate  into  the  excluded  loop,  which  is  of  no  parti- 
cular moment,  as  they  are  again  expelled.  The  approximation  can  be  best  made  with 
the  round  button  in  end-to-side  anastomosis,  or  with  the  oblong  button  in  side-to- 
side  union.  It  can  be  performed  quickly,  and  in  the  presence  of  tuberculous  lesions 
and  multiple  fistulae  with  extensive  adhesions  is  a  life-saving  procedure. 

Complete  or  Bilateral  Enteric  Exclusion. — This  procedure,  first  practised  by 
Trendelenburg  in  1880  for  inoperable  carcinoma  of  the  cecum,  with  fatal  result, 
consists  in  excluding  a  segment  of  intestine  by  closing  both  ends  of  the  excluded 
portion.  When  the  operation  is  performed  for  fistula  or  tuberculosis,  both  ends  of 
the  segment  are  shut  oft'  from  the  rest  of  the  bowel ;  the  ends  may  be  inverted  and 
closed.  When  there  is  no  fistula,  one  end  is  brought  out  on  the  surface  and  sutured 
to  the  skin;   this  opening  is  maintained  as  a  drain.     Although  the  discharge  dimin- 

^  Trzebicky,  R.:  "Ueber  die  Grenzen  der  Zulassiaikeit  der  Dunndarmresection,"  Arch.  f. 
klin.Chir.,1894,  xlviii,54. 

^  Koeberle,  E.:  "Resection  de  deux  metres  d'intestin  grele  suivre  de  guerison,"  Bull,  et  M6m. 
Soc.  de  Chir.,  1881,  vii,  99. 

^  Morton:  Personal  communication  to  author. 

*  Pauchet,  V. :  "Resection  de  4  metres  d'intestin  grele,"  Gaz.  d.  Hopitaux,  1905,  Ixxviii,  1667. 


INTESTINAL    REPAIR. 


443 


ishes  rapidly  and  atrophy  of  the  segment  takes  place,  it  is  never  complete  enough  to 
permit  closure  of  the  fistula.  After  the  inflammatory  conditions  have  subsided  and 
the  surrounding  infiltration  has  disappeared,  during  which  time  the  patient  may  have 
sufficiently  recuperated,  the  diseased  portion  may  be  excised  with  but  little  danger. 
In  all  pelvic  operations  in  which  the  intestine  has  been  opened,  drainage  by  either  the 
suprapubic  or  the  vaginal  route  should  be  instituted.  Infection  is  the  rule,  and 
unless  drainage  is  maintained  there  is  danger  not  only  to  the  line  of  union,  but  to  the 
life  of  the  patient  as  well.  The  number  of  inches  of  intestine  which  may  be  excluded 
varies  greatly.     In  general,  as  many  inches  may  be  excluded  as  may  be  excised. 


Fig.  654. — Side-to-side  Approximation  op  Ileum  to  Descending  Colon  with  Oblong  Mdrphy  Button. 


The  technic  of  these  operations  is  the  same  as  in  end-to-end  and  side-to-side  ap- 
proximations, and  needs  no  detailed  description. 

Artificial  Anus ;  Fecal  Fistula. — An  artificial  fecal  fistula  is  made  by  bringing 
a  loop  of  the  small  bowel  into  the  abdominal  wall,  and  is  done  either  to  relieve  disten- 
tion or  to  allow  the  introduction  of  nourishment. 

Kocher's^  method  is  to  make  an  incision  2t}  inches  long  and  l.j  inches  above 
Poupart's  ligament,  parallel  to  the  epigastric  artery;  the  tissues  are  incised  down  to 
the  peritoneum;   the  distended  loop  is  then  brought  into  the  abdominal  wound  and 

'  Kocher,  Th.:    "Operative  Surgery,"  New  York,  1894. 


444 


INTESTINAL   SURGERY. 


two  silkworm-gut  sutures  passed 
through  all  the  tissues  of  the  bowel, 
including  the  serosa;  the  latter  is 
then  fixed  to  the  peritoneum  by  a 
continuous  suture.  A  second  cat- 
gut suture  unites  the  skin  and  the 
seromuscular  coats  of  the  bowel. 
The  bow^el  is  then  opened,  either 
immediately  or  in  a  few  days,  when 
adhesions  have  taken  place. 

An  artificial  anus  or  colostomy 
is  an  opening  into  the  large  intes- 
tine for  the  purpose  of  prolonging 
life,  especially  in  obstruction  from 
malignant  disease,  and  occasion- 
ally to  divert  the  current  tempor- 
arily for  the  aseptic  repair  of  the 
bowel  further  down.  Lvmibar 
colostomy  was  the  method  used 
formerly,  but  today  this  is  supplanted  by  the  inguinal  or  abdominal  methods.     The 


Fig.  655. — Technic  of  Colostomy  for  1i,(  ai.  1  im  i  i.a    after 

Kocher). 

a,  Reflected  peritoneum;    b,  catgut  passed   through    wall    of 

bowel. 


I-T.JBecKe~Ao 


Fig.  656. — Technic  of  Inguinal  Colostomy. 
a,  Line  of  suture  of  parietal  peritoneum  to  intestinal  serosa;    b,  gauze  passed  under  loop  of  colon. 


operation  is  attended  by  little  danger.     Allingham^  performed  inguinal  colostomy 
'  Allingham,  W.  and  H.  W. :   "Diseases  of  the  Rectum,"  London.  1901. 


INTESTINAL   REPAIR. 


445 


sixty-eight  times  with  only  two  deaths;  Cripps^  had  one  hundred  and  forty-three 
cases  with  sixteen  deaths;  and  Edwards  sixteen  cases  with  one  death.  Strauss' 
statistics  show  a  mortahty  of  less  than  2  per  cent. 

Technic  of  Inguinal  or  Iliac  Colostomy  (Fig.  656). — Cover  the  entire  field  of 


Fig.  657. — Technic  of  Colostomy  by  Bodine's  Method  (Bryant). 
Line  of  suture  preparatory  to  the  application  of  Grant's  clamp. 


Fig.  658. — Technic  of  Bodine's  Colos- 
tomy- (Bryant). 
Method  of  application   of  Grant's  enter- 
otome. 


operation  with  the  adhesive  rubber  dam,  8  inches  square  (this  can  be  kept 
on  for  many  weeks,  preventing  irritation  of  the 
skin).  An  incision  is  made  2  inches  above  Pou- 
part's  ligament,  through  the  skin,  adipose  tissue, 
and  fascia;  then  the  fibers  of  the  external  oblique, 
the  transversalis,  and  the  internal  oblique  are  separ- 
ated parallel  to  their  long  axes  by  blunt  dissection, 
and  the  peritoneum  is  incised.  The  finger  is  then 
passed  down  to  the  iliac  vessels  and  hooks  up  the 
large  intestine.  The  colon  is  now  drawn  down  as 
far  as  possible.  The  mesocolon  is  then  split  at  its 
junction  with  the  bowel,  and  a  glass  rod,  rubber 
tube,  or  gauze  passed  through  the  opening.  The 
intestine  is  now  secured  in  the  abdominal  wound  by 
interrupted  sutures  passing  through  the  seromus- 
cular layers  of  the  bowel  and  parietal  peritoneum, 
and  the  peritoneum  and  muscles  are  united  by 
sutures  through  the  slit  in  the  mesentery  per- 
manently, preventing  the  bowel  from  dropping  back  into  the  abdomen.  The 
bowel  may  be  opened  in  two  or  three  days,  thus  establishing  the  artificial  anus. 


Fig.  659. — Technic  of  Lumb.\r  Colos- 
tomy. 

S,  Sigmoid  sutured  to  skin;  s,  line  of 
suture. 


^  Cripps,  H.:    "Diseases  of  the  Rectum  and  Anus,"  London,  1907. 


446 


INTESTINAL    SURGERY. 


If  obstruction  is  present  at  the  time  of  operation,  the  bowel  must  be  opened  at  once, 
and  its  edge  accurately  sutured  to  the  skin  with  horsehair. 


Fig.  660. — Technic  of  Lumbar  CoLOSTOirv. 
Line  of  incision. 

Bodine's  ^  Method  (Figs.  657  and  658). — The  abdominal  wall  is  opened  as  above; 
the  peritoneum  is  split  and  its  edges  secured  from  retraction.     A  long  loop  of 

large  intestine  is  drawn 
out  through  the  open- 
ing and  the  serosa  of 
the  distal  and  proxi- 
mal ends  is  sutured 
laterally  for  a  dis- 
tance of  about  6 
inches.  The  bowel  is 
then  returned  to  the 
abdomen,  lea^'ing  only 

-latLssimus    a  small  segment  out- 

cLorsi.  side  the  wound.     This 

is  stitched  accurately 


exUrn.and  inter 
otUque 


transvers.  muiicCe 


Qiuidr, 


Fig.  661.— Technic  o 

Sigmoid  exposed. 


^  Bodine:  (quoted)  in 
Bryant's  "  Operative  Sur- 
gery'," New  York,  1905. 


FISTULA. 


447 


to  the  wound  margins  with  horsehair  and  opened  at  once.  If  it  is  desired  to  close 
the  opening  later  on,  the  spur  may  be  removed  by  Grant's  enterotome  and  the  bowel 
and  outer  opening  sutured. 

Cripps'  Method. — The  incision  is  very  short  and  is  on  a  level  with  the  umbilicus; 
the  peritoneum  in  this  method  is  stitched  to  the  skin  by  several  interrupted  sutures; 
a  loop  of  large  bowel  is  then  drawn  out,  two-thirds  of  its  circumference  being  above 
the  level  of  the  incision.  The  bowel  is  now  sutured  to  the  peritoneum  and  skin,  the 
sutures  through  the  lower  lip  of  the  wound  being  passed  through  the  inferior  longi- 
tudinal band,  those  of  the  upper  lip  through  the  muscularis  and  near  the  attachment 
of  the  mesentery. 

Lumbar  colostomy  (Figs.  659,  660,  661),  as  stated  before,  is  seldom  practised  at 
present;  when  performed  at  all,  it  is  on  the  left  side.  An  oblique  incision  3  inches 
long  is  made  parallel  to  the  crest  of  the  ilium  and  down  to  the  aponeurosis.  It  is 
very  important  to  avoid  injuring  the  twelfth  intercostal  nerve,  the  large  trunk  of 
which  appears  very  conspicuous  in  the  wound.  The  peritoneum  is  opened  from 
behind,  a  loop  of  bowel  is  grasped  or  hooked  up,  and  after  being  stitched  to  the 
peritoneum  and  opened,  its  divided  edge  is  accurately  secured  to  the  skin.  The 
subsequent  closure  of  all  types  of  artificial  anus  should  be  made  after  the  plan  of 
closure  of  intestinal  fistulse,  described  later.  The  Dupuytren  clamp  and  all  methods 
requiring  its  principle  are  hazardous. 


FISTULA. 

Fistulse  between  the  gastro-intestinal  canal  and  the  genito-urinary  tract  are  not 
uncommon  in  gynecologic  surgery. 

Nephro-enteric  Fistula. — The  most  common  form  of  communication  between 
the  kidney  and  the  intestinal  tract  is  that  with  the  as- 
cending or  descending  colon  (Fig.  662). 

Etiology. — Renal  infections  may  penetrate  through 
the  anterior  surface  of  the  kidney  or  the  pelvis  of  the 
latter  in  the  direction  of  the  peritoneal  cavity.  Peri- 
nephric abscesses  may  open  into  the  kidney  and  also 
into  the  colon.  Tuberculosis  and  malignant  growths 
of  the  kidney  after  they  extend  to  the  capsule  of  the 
organ  may  communicate  w4th  the  colon.  Calculus  is 
by  far  the  most  common  cause.  The  mere  presence 
of  a  calculus  does  not  cause  a  fistula  unless  there  is 
pressure  exerted  on  the  organ;  the  size  is  a  lesser  etio- 
logic  factor  than  the  accompanying  infection  which 
necrotizes  the  tissues.  On  the  other  hand,  the  patho- 
logic condition  may  originate  in  the  intestine,  especially  as  a  tuberculosis.  Cysts 
of  the  kidney  may  rupture  into  the  intestine;  Kiister^  has  collected  one  hundred 

*  Kiister,    Ernst  :     "  Die   Chirurgie    der   Nieren,    der    Harnleiter   und    der    Nebennieren," 
Deutsche  Chirurgie,  1896-1902,  Lief.  52  b. 


Fig.  662. — Nephro-enteric  Fistula. 

I,  Intestine;    k,  kidney  substance;    /, 

fistula. 


448 


INTESTINAL   SURGERY. 


Fig.  663. — Pyelo-enteric  Fistula 

i,  Intestine;  p,  pelvis  of  kidney;   k 

kidney  proper;  j,  fistulous  tract. 


and  fifty-three  cases  of  this  character.     (The  symptoms,  diagnosis,  and  treatment 
will  appear  later.) 

Pyelo-enteric  or  Uretero-enteric  Fistula. — A  communication  between  the 

pelvis  of  the  kidney  and  the  bowel  may  be  either  direct 
or  indirect  (Figs.  663,  664).  The  recorded  cases  are 
few  in  number;  Hilgenreiner ^  was  able  to  collect  only 
twenty-two. 

Etiology. — Pyelitis,  tuberculosis  with  pyelonephro- 
sis,  perinephric  abscess.  The  colon  is  the  most  com- 
mon seat.  A  communication  with  the  duodenum  is 
rare,  and  with  the  other  parts  of  the  small  intestine 
still  more  so.  According  to  Lieblein  and  Hilgenreiner,^ 
the  fistulse  were  located  in  the  colon  thirteen  times; 
three  in  the  duodenum,  and  only  one  in  the  ileum.  In 
a  case  reported  by  Murchison,^  a  tuberculous  infection 
of  the  left  kidney  perforated  into  the  descending  colon 
and  also  into  the  stomach  at  the  cardia.  In  case  of 
pyelo-enteric  fistula  the  kidney  is  enlarged  and  be- 
comes adherent  to  the  contiguous  segment  of  intestine. 
The  parenchyma  of  the  organ  is  destroyed  and  the  intestinal  mucosa  becomes 
greatly  changed  in  character  by  the  irritation  of  the  urine. 

Sym'ptoms. — Before  the  patient  becomes  aware  of  the  true  condition  he  com- 
plains of  either  bladder  or  bowel  trouble.  Careful  ob- 
servations by  him  may  have  shown  pus  in  the  feces.  If 
the  communication  is  below  the  third  portion  of  the  duo- 
denum, there  is  no  vomiting,  as  a  rule.  If,  however,  it 
involves  the  first  or  second  portions,  the  patient  may 
have  regurgitation  of  urine,  feces,  or  pus  (Champaig- 
nac*).  The  feces  have  the  odor  of  ammonia  and  the 
urine  that  of  sulphuretted  hydrogen.  Examination  of 
the  urine  reveals  the  presence  of  urea,  uric  acid,  and, 
occasionally,  casts.  WTiile  urea  and  uric  acid  may  be 
found  in  the  feces  in  small  quantities,  acid  salts  (uric 
acid  and  urates)  must  lead  one  to  suspect  fistula,  since 
we  know  the  salts  of  the  feces  (phosphates)  are  alkaline. 
Diagnosis  may  be  made  on  the  strength  of  the  above- 
mentioned  symptoms,  in  addition  to  which  a  history  of 

pain  or  lumbar  tumor  may  be  elicited.     Cystoscopic  examination   will   also  aid 
materially  in  the  diagnosis.     A  dish  of  berries  containing  small  seeds  is  a  very 

1  Lieblein  unci  Hilgenreiner:    "Die  Geschwiire  und  die  erwobenen  Fisteln  des  Magen-Darm- 
kanals,"  Deutsche  Chirurgie,  1905,  Lief.  46C. 
^  Lieblein  and  Hilgenreiner:    Loc.  cit. 
^Murchison:  Quoted  by  Lieblein. 
*Champaignac:   Quoted  by  Lieblein. 


Fig.  664. — Uretero-enteric  Fis- 
tula. 
i,  Intestine;  u,  ureter;  /,  fistula. 


FISTULA.  449 

efficient  test,  as  the  seeds  will  pass  through  small  openings  into  the  urinary  tract 
which  would  not  admit  gas  or  feces. 

Prognosis. — This  is  grave.  The  patients  gradually  lose  strength  from  the  chronic 
diarrhea,  and  succumb  from  inanition  within  a  few  months  to  a  year  or  two.  Very 
few  of  them  live  over  five  years,  although  Mikulicz^  saw  one  of  ten  years'  and  Keen^ 
one  (enterovesical)  of  twenty  years'  standing. 

Treatment. — In  nephro-enteric  fistulse,  with  the  exception  of  the  tuberculous  type, 
the  operation  will  consist  of  some  of  the  extraperitoneal  procedures.  The  technic 
will  be  the  same  as  that  for  abdominal  operations  in  general.  Where  one  kidney  is 
seriously  involved  from  a  pathologic  standpoint,  the  best  course  to  pursue  is  removal, 
provided  the  other  one  has  a  urea  sufficiency. 

In  pyelo-uretero-intestinal  fistula  the  leaking  ureter  should  be  reached  by  the 
extraperitoneal  route  and  separated  from  the  intestine.  The  pus  cavity  between  the 
ureter  and  the  intestine  must  be  excised  or  drained.  After  drainage  is  kept  up  for 
some  time,  the  infiltrated  zone  contracts  and  may  permit  excision  of  the  diseased 
portion  of  the  ureter,  and  end-to-end  implantation.  The  kidney  should  be  preserved 
if  possible,  since  the  ureter  has  great  recuperative  power.  Suture  of  the  ureter  in 
the  zone  of  infiltration  is  impracticable.  Healing  of  the  ureter  may  be  obtained  by 
separating  the  adhesions  between  it  and  the  intestine,  with  subsequent  drainage 
of  the  abscess  cavity.  As  far  as  the  intestine  is  concerned,  the  same  rule  governs 
all  intestinal  fistulse — first,  free  the  adhesions,  and  then  close  the  opening  by  double 
Lembert  sutures. 

Removal  of  the  kidney  should  not  be  resorted  to  until  it  has  been  established 
that  a  restoration  of  the  ureter  is  impossible,  and  never  until  it  is  established  beyond 
all  doubt  that  the  other  kidney  is  physiologically  equivalent.  It  is  desirable,  be- 
fore proceeding  to  the  operation,  to  introduce  a  stilet-uretefal  catheter  through  the 
bladder.  If  the  fistula  is  accompanied  by  symptoms  of  renal  infection,  the  first  step 
is  to  provide  drainage  so  as  to  save  it  from  the  destructive  effects  of  the  accumulated 
pus.  Intestinal  implantation  of  the  ureter  can  be  easily  accomplished  technically 
(Martin),  but  the  ultimate  effects  on  the  kidney  are  disastrous  owing  to  an  ascending 
pyelitis.  Mathes  in  1897  collected  twenty-five  cases  of  implantation  of  the  ureter 
in  this  manner  with  seven  deaths. 

The  end  of  the  ureter  may  be  turned  out  and  attached  to  the  skin,  establishing  a 
permanent  urinary  fistula,  with  little  if  any  danger  to  life.  Extirpation  of  a  normally 
secreting  kidney  under  these  circumstances  should  never  be  resorted  to,  as  it  in- 
volves a  mortality  of  30  per  cent.,  while  a  kidney  in  which  a  functional  capacity  has 
been  gradually  destroyed  or  greatly  reduced  involves  a  nephrectomy  mortality  of 
less  than  3  per  cent.  Expressed  as  a  law :  The  greater  the  destruction  of  the  functional 
capacity  of  the  kidney,  the  less  the  danger  of  nephrectomy. 

Among  the  most  important  etiologic  factors  are  pelvic  infection,  post-abortive 

or  post-parturient  in  origin;    neoplasms  of  the  intestine  or  bladder;    tuberculous 

enteritis,  peritonitis,  or  cystitis ;  vesical  calculus.     I  recently  had  a  pehnc  infection  in 

1  Mikulicz,  J. :  Quoted  by  Lieblein.  ^  Keen,  W.  W. :    Quoted  by  Hilgenreiner. 

VOL.  II — 29 


450  INTESTINAL   SURGERY. 

which  fourteen  intestinal  fistulse  communicated  with  a  common  bladder  atrium. 
I  had  another  case  in  which  a  carcinoma  of  the  sigmoid  led  through  two  openings  into 
the  bladder.  In  both  cases  I  resected  the  diseased  intestine  and  contiguous  bladder 
wall  and  the  patients  made  good  recoveries.  Trauma  during  parturition ;  pelvic  and 
abdominal  operations;  foreign  bodies  in  the  bladder  and  intestine,  and  abdominal 
contusions  may  also  be  responsible  for  perforations.  A  case  is  recorded  in  which  a 
needle  penetrated  the  appendix,  the  latter  became  adherent  to  the  bladder,  and 
finally  the  latter  was  perforated.  Post-operative  fistulae  are  not  uncommon,  especi- 
ally between  the  rectum  and  the  bladder.  In  pathologic  fistulse  the  disease  may  origi- 
nate primarily  in  the  bladder  or  intestine,  or  may  follow  infection  of  the  surrounding 
tissue.     The  initial  lesion  is  most  frequent  in  the  intestine. 

Enterovesical  Fistulae. — In  the  cases  of  en tero vesical  fistulte  collected  by 
Pascal  in  his  monograph,  the  cecum  and  appendix  were  involved  in  seventeen,  the 
rectum  in  nine,  and  the  small  intestine  in  eight.  Apphun  collected  twenty-six  cases 
of  fistula  between  the  appendix  and  the  bladder.  The  morbid  conditions  of  the 
bowel  responsible  were:  chronic  diarrhea  in  4;  toxic  enteritis,  typhoid  perforation, 
perforation  of  Meckel's  diverticulum,  and  tuberculosis  of  the  intestine,  each  one 
(Pascal).  Among  the  diseases  of  surrounding  organs  or  tissues,  may  be  mentioned 
pelvic  peritonitis,  salpingitis,  tuberculous  and  malignant  conditions  of  the  pelvic 
organs. 

Heine,  of  Dresden,  analyzed  400  cases  of  fistulse  between  the  bladder  and  bowel. 
Of  these,  only  8  (2  per  cent.)  originated  from  a  diverticulum  of  the  intestine.  These 
diverticula  may  be  either  congenital  or  acquired.  The  latter  variety  results  from 
inflammatory  processes  either  of  the  bladder,  the  intestine,  or  of  the  tissues  between, 
with  subsequent  plastic  exudate  and  final  adhesion  and  traction.  This  may  take 
place  between  the  intestine  and  bladder,  intestine  and  vagina,  etc.  The  bladder 
being  a  more  fixed  organ,  it  can  readily  be  seen  that  adhesions  between  it  and  the  in- 
testine, especially  to  a  distant  coil,  will  cause  traction  on  the  wall  of  the  intestine,  and 
result  in  the  formation  of  a  false  diverticulum.  The  wall  of  the  latter  is  thinner 
than  that  of  the  bowel,  and  as  a  result  of  inflammation  and  adhesion,  perforation 
may  occur.  The  infiltration  which  occurs  in  the  diverticulum  and  the  surrounding 
tissue  may  simulate  malignant  disease  and  thus  mislead  the  surgeon.  This  is 
particularly  true  in  the  sigmoid  zone. 

Pathologic  Anatomy. — These  fistulse  are  usually  located  in  the  posterior  wall  of 
the  bladder  in  the  vicinity  of  the  trigone.  This  is  more  uniformly  the  case  when  the 
communication  is  between  the  recti^m  and  the  bladder.  When  it  is  between  the 
bladder  and  the  large  or  small  intestine,  the  opening  is  commonly  on  the  side.  The 
fistulous  opening  is  seldom  or  never  on  the  anterior  surface  of  the  bladder.  Of 
the  one  hundred  and  five  cases  collected  by  Pascal,  in  four  the  opening  was  in  the 
colon  and  sigmoid;  in  sixteen  in  the  appendix  and  cecum;  in  twenty-eight  in  the 
small  intestine,  while  in  the  remainder  the  openings  were  either  multiple  or  so 
situated  they  could  not  well  be  classified.  When  the  enterovesical  fistula  is  due  to  a 
diverticulum,  the  opening  in  87  per  cent,  is  in  the  sigmoid. 


FISTULA.  451 

Symptoms. — The  three  pathognomonic  symptoms  are  pneumaturia,  fecaluria, 
and  pyuria.  There  may  be,  in  addition,  pain  in  the  suprapubic  and  lumbosacral 
regions,  either  independent  or  concomitant.  In  the  later  stages  the  constant  ir- 
ritation may  give  rise  to  additional  symptoms,  as,  for  instance,  hematuria.  As  the 
duration  of  the  disease  decreases,  the  patient  becomes  emaciated,  especially  when  the 
fistula  is  the  result  of  malignant  disease. 

Occasionally  even  the  classic  symptoms  may  be  misleading.  Pneumaturia, 
for  instance,  may  occur  after  the  performance  of  lithotripsy  or  on  the  opening  of  an 
abscess  due  to  gas-producing  bacilli.  In  diabetes  if  the  patient  is  catheterized  with 
instruments  not  perfectly  clean,  yeast  cells  may  be  introduced  which  split  the  sugar 
into  alcohol  and  carbonic  acid,  thus  giving  rise  to  temporary  pneumaturia. 

While  the  examination  of  the  urine  is  of  primary  importance  for  establishment  of 
the  diagnosis,  it  must  not  be  forgotten  that  residual  urine  may  become  alkaline,  so 
when  the  urine  suspected  of  containing  feces  is  tested,  it  w^ill  be  alkaline  and  may 
mislead  one.  When  the  opening  is  between  the  rectum  and  the  bladder,  procteal 
combined  with  cystoscopic  examination  will  readily  establish  the  diagnosis.  Patent 
urachus  and  vesical  diverticula  must  not  be  mistaken  for  enteric  fistulse.  The  best 
means  of  establishing  the  diagnosis  of  a  communication  between  the  bladder  and  the 
intestine  is  the  "strawberry  diet-test,"  as  the  seeds  pass  into  the  bladder. 

Prognosis. — This  is  generally  unfavorable.  Spontaneous  healing  is  rare,  even 
in  non-malignant  cases.  There  was  a  mortality  of  8  per  cent,  in  the  series  collected 
by  Lieblein  and  only  five  cases  of  spontaneous  cure. 

Treatment  may  be. prophylactic  or  radical.  Inspection  of  the  bladder,  intestine, 
or  the  tissues  contiguous  to  these  organs  should  be  timely.  When  the  history  is 
obscure  or  there  is  absence  of  evidence  of  acute  inflammatory  conditions,  the  pos- 
sibility of  syphiUs  may  be  borne  in  mind.  In  Kuthe's  case  the  fistula  was  of  specific 
origin,  and  appropriate  treatment  led  to  its  cure. 

Radical  Treatment. — Colostomy  is  one  of  the  oldest  methods.  It  is  performed 
in  the  usual  way  so  as  to  prevent  the  feces  from  entering  the  fistulous  opening; 
it  is  an  unsatisfactory  substitute. 

In  exclusion  of  the  fistulous  zone  of  the  intestine,  unilateral  and  bilateral,  the 
former  has  not  given  good  results,  as  feces  continue  to  gain  access  to  the  bladder,  and 
urine  to  the  bowel.  The  bilateral  method  when  a  small  zone  is  shut  off  is  successful, 
though  it  often  requires  a  second  operation  for  excision. 

Suture  of  vesical  fistula: 

(a)  Through  vesicovaginal  route  (Simon^). 

(h)  Transvesical  (LeDentu^). 

(c)  Symphysis  route  (I^angenbuch).  A  Y-shaped  incision  is  made  in  such  a 
manner  as  to  have  the  vertical  branch  of  the  Y  along  the  linea  alba  and  the  arms  on 
either  side  of  the  pubes;  the  latter  may  or  may  not  be  resected. 

{d)  Mechan's  incision,  in  which  the  bladder  is  reached  by  a  lateral  incision 

1  Simon,  G.:  "Operation  der  ©lasenscheidenfistel,"  Wien.  med.  Woch.,  1876,  xxvi,  692. 

2  LeDentu,  A.:  "Affections  chirurgicales  des  reins  et  des  ureteres,"  Paris,  1889. 


452 


INTESTINAL   SURGERY. 


along  the  pubis  and  temporary  resection  of  the  same,  giving  access  to  the  bladder 
by  the  extraperitoneal  route. 

(e)  The  perineal,  sacral,  and  rectal  routes  are  advisable  for  rectovesical  fistulse 
only. 

All  these  procedures  are  of  some  importance  from  a  historic  standpoint,  but  they 
cannot  be  applied  safely  and  practically  today,  therefore  the  writer  advocates  the 
transperitoneal  method.  The  rule  governing  all  enteric  fistulse  applies  with  equal 
force  to  the  enterovesical  type.  The  first  step  is  separation  of  all  adhesions  in  close 
proximity  to  the  communicating  canal.  After  these  are  freed  sufficiently  to  allow 
lifting  up  of  the  intestine  and  bladder,  the  fistula  may  be  opened  and  clamped  so 
as  to  prevent  leakage  into  the  peritoneal  cavity;  it  must  be  examined,  and  if  it  in- 
volves more  than  50 
per  cent,  of  the  cir- 
cumference of  the  in- 
testine, a  transverse 
line  of  suture  is  pre- 
ferable to  the  longi- 
tudinal. In  suturing 
a  large  opening  by  this 
transverse  method 
great  care  should  be 
exercised  at  the  mes- 
enteric border,  as  this 
is  the  danger-point  in 
all  methods  of  intes- 
tinal approximation. 
A  double  Lembert 
whip-stitch  or  over- 
and-over  stitch  gives 
the  best  results  in  re- 
pair of  intestinal  fis- 
tula, as  there  is  con- 
siderable mural  infiltration  in  these  cases.  If  the  infiltration  of  the  intestinal 
wall  is  such  that  accurate  suturing  cannot  be  done  without  great  tension  or  kink- 
ing, a  resection  should  be  made,  with  subsequent  approximation  with  the  round 
button  or  suture.  If,  as  occasionally  happens,  the  intestinal  wall  on  the  proximal 
side  of  the  fistula  is  impaired  from  the  resultant  obstruction,  an  end-to-end  approxi- 
mation should  not  be  attempted,  but  the  side-to-side  method  with  oblong  button  or 
suture  resorted  to.  This  line  of  suture  should  always  be  on  the  convex  border  of  the 
bowel,  never  on  the  mesenteric. 

The  most  frequent  cause  of  failure  in  the  repair  of  intestinal  fistula  is  the  fact  that 
the  intestine  is  not  sufficiently  liberated  from  its  adhesions  to  the  neighboring  struc- 
tures.    The  bladder  opening  is  fixed  by  gastrectomy  clamps  (Mayo's  or  Bernays') 


Fig.  665. — Technic  of  Repair  op  Enterovesical  Fistulse. 
Gastrectomy  clamps  applied;  double  row  of  continuous  mural  sutures 


FISTULA. 


453 


outer(serousj  suiure 


jjnnerfjniirAl)  saiiue 


Fig.  666. — Technic  of  Repair  of  Enterovesical  Fistul.e. 
Gastrectomy  clamps  applied;    double  row  of  continuous  mural  sutures. 


(Figs.  665,  666).  The  infiltrated  zone  of  the  bladder  wall  around  the  fistula  is 
dissected  out  completely,  and  an  accurate  very  close  suture  made  ot  all  the  coats 
down  to  the  mucosa.  The  continuous  stitch  is  the  best,  and  "fifteen-day  catgut" 
the  safest  material  to 
use.  A  second  row 
of  sutures  (Lembert) 
with  chromicized  cat- 
gut should  be  made; 
this,  however,  involves 
the  peritoneum  and 
the  outer  portion  of 
the  muscular  coat, 
making  a  lateral  rather 
than  an  edge-to-edge 
approximation  outside 
the  first  line  of  suture. 
A  rubber  tube  (No.  24 
French)  should  be  in- 
serted in  the  bladder 
and  fixed  to  the  ure- 
thra with  silkworm-gut.  Three  or  four  holes  are  made  in  this  tube  at  the  distal  end. 
This  is  better  than  a  catheter,  as  it  is  softer  and  has  a  larger  lumen.  The  drain  is 
left  in  fifteen  days.  If  ordinary  commercial  catgut  is  used,  there  is  danger  of  sep- 
aration of  the  line  of  suture.     The  peritoneum  should  have  tubal  glass  or  rubber 

drain.  The  patient  is  kept  in  the  Fowler  position 
for  four  days.  When  the  fistula  is  between  the 
bladder  and  the  rectum  or  sigmoid,  a  rubl)er  tube 
I  inch  in  diameter  should  be  inserted  in  the  rectum 
and  retained  there  by  a  peri-anal  suture  of  silk- 
worm-gut. This  step  prevents  tension  from  gas  in 
the  large  bowel,  thereby  greatly  favoring  the  success 
of  the  operation. 

Perineal  Route. — The  fistula  may  involve  the 
bladder  (Fig.  667),  intestine,  and  vagina  simultan- 
eously. The  first  and  most  important  step  in  the 
management  of  such  fistulse  is  an  extensive  separ- 
ation of  the  adhesions  between  the  various  organs. 
After  this  is  thoroughly  accomplished,  the  bladder  is 
closed  as  above  described.  The  bowel  must  be 
closed  with  longitudinal  sutures,  and  an  iodoform  gauze  drain  maintained  be- 
tween the  two  organs.  This  should  not  be  removed  until  the  fifteenth  day,  when 
sufficient  time  will  have  elapsed  for  organic  union.  If  the  rectum  or  lower  por- 
tion of  the  sigmoid  is  infiltrated  to  a  considerable  degree,  a  combined  perineo- 


FiG.  667. — Enterovesical  Fistula. 
i,  Intestine;  b,  bladder;  f,  fistula. 


454 


INTESTINAL   SURGERY. 


abdominal  operation  with  resection  of  the  infiltrated  intestine,  and  transplantation  of 
the  sigmoid  connecting  it  with  the  sphincteric  end  which  has  been  retained,  gives  the 
best  results.  It  is  surprising  how  much  of  the  sigmoid  can  be  brought  down  without 
jeopardizing  the  circulation.  End-to-end  union  with  suture  through  a  complete 
rectovaginal  division  of  the  perineum  gives  the  best  field  for  operation,  with  a  fair 
assurance  of  success.  In  all  of  the  above  operations  a  permanent  vesical  catheter 
and  rectal  tube  must  be  employed  to  prevent  tension. 

Enterogenital  Fistulas. — By  these  we  understand  communications  between  the 
small  and  large  intestine  (not  including  the  rectum)  and  the  genitalia.  This  type 
of  fistula  is  not  common.  Narath  after  a  careful  search  through  the  Kterature  for  the 
last  hundred  years  was  unable  to  collect  more  than  forty  cases.  Lieblein  and 
Hilgenreiner^  collected  enough  more  to  bring  the  number  up  to  one  hundred  and 
twenty- two. 

Etiology. — These  fistulae  are  either  congenital  or  acquired.  The  latter  alone 
will  be  considered  here.  It  may  be  due  to  manipulation  during  attempted  abortion, 
extrauterine  pregnancy,  or  labor.  In  the  twenty-eight  cases  of  communication 
between  the  gastro-intestinal  tract  and  the  uterus  collected  by  Neugebauer,  one-half 
were  due  to  retained  and  necrotic  fetuses  or  parts  of  fetuses.  The  application  of 
forceps  during  delivery  or  the  rupture  of  the  uterus  is  responsible  for  some  of  these. 
The  organ  perforated  is  either  the  uterus  or  the  vagina.  A  loop  of  gut  protrudes 
through  the  opening,  is  constantly  compressed,  becomes  necrotic,  and  finally  its 
wall  gives  way.  Curetment  for  the  removal  of  the  placenta  may  cause  a  per- 
foration of  the  uterus.  In  a  case  of  Rosenthal's  a  fecal  fistula  into  the  vagina 
formed  after  manual  removal  of  the  placenta.  In  cases  of  post-partum  sepsis 
a  coil  of  intestine  may  become  adherent  to  the  peri-uterine  exudate  and  finally 
perforate  it. 

Enterogenital  fistulse  are  occasionally  met  with  independent  of  pregnancy  and 
labor.  Among  the  causes  may  be  mentioned  curetment,  trauma,  the  use  of  pes- 
saries, vaginal  hysterectomies,  etc.  They  may  also  be  of  intestinal  origin,  arising 
from  tuberculosis  of  the  small  intestine,  appendicitis,  diverticula,  or  malignant 
growths. 


Fistula  of  Genital  Origin. 

Intestinal 
Origin. 

Unknown 

Origin. 

Total. 

Ohigin. 

Puerperal. 

Post-operative. 

Other. 

1 

47 

47 

12 

5 

13 

125 

The  order  of  frequency  of  occurrence  of  these  fistulse  is :  enterovaginal,  entero- 
uterine,  enterotubal.  Of  one  hundred  and  two  cases,  fifty-nine  were  of  vaginal 
origin,  forty-one  uterine,  and  two  tubal. 

^  Lieblein  and  Hilgenreiner:  Deutsche  Chirurgie,  Lieferung  46  C,  1905. 


FISTULA. 


455 


The  following  table^  shows  the  topography  of  these  fistulse: 


Number  of 
Cases. 

Number  of  Fistulous  Openings. 

Varieties. 

Small  Intes-    '    Large  Intes- 
tine.          [           tine. 

Both  Large 
and  Small 
Intestines. 

Total 

Number  of 

Fistula. 

Enterovaginal 

Entero-uterine    

57 
37 

46 
25 

24 

10 

13 

2 

3 

3 
3 

59 
41 

Enterotuba] 

Post-operative 

2 
26 

2 

27 

Total '. 

122                    95 

28 

6 

129 

The  location  of  the  fistulse  as  shown  by  the  table  is  in  the  small  bowel,  as  a  rule, 
and  in  its  movable  segments. 

Enterovaginal  Fistulae  (Fig.  668). — These  may  be  due  to  rupture  of  the  vagina 
during  parturition,  allowing  extrusion  of  a  coil  of  intestine  with  subsequent  gangrene 
and  rupture.     Pressure  on  a  coil  of  intestine  ,^ 

in  the  posterior  cul-de-sac  during  pregnancy 
may  cause  inflammation,  with  subsequent 
adhesions  and  ultimate  perforation.  Malig- 
nant tumors  of  the  uterus,  the  broad  liga- 
ments, or  surrounding  tissues  may  confine  a 
coil  of  intestine  in  the  cul-de-sac,  and  this  in 
time  may  become  perforated.  Vaginal 
drainage  of  tubes  may  be  responsible  for  a 
fistula;  and  the  clamp  method  in  hysterec- 
tomy is  often  a  cause.  Trauma  or  foreign 
bodies  may,  but  rarely,  cause  perforations. 
A  fistula  was  caused  by  the  branch  of  a  tree 
penetrating  the  vagina  while  the  patient  was 
descending  (Walk). 

Among  the  indirect  causes  of  perforations 
are  infections  and  abscesses.  The  surgeon 
in  attempting  to  open  these  abscesses  may 

perforate  the  adherent  coil  of  intestine  or  the  thin  attachment  of  the  intestinal  wall. 
These  communications  are  always  high  up,  and  on  the  posterior  wall,  as  a  rule;  in 
some  cases  they  are  situated  laterally. 

The  symptoms  are  described  as  escape  of  flatus  and  feces  through  the  vagina. 
The  prognosis  is  unfavorable.  While  spontaneous  healing  is  rare,  examples  are 
recorded  (McKeever). 

Treatment. — (a)  Prophylactic  (the  prophylaxis  of  these  fistulee  is  considered 
under  "Prophylaxis  of  Injuries  to  the  Intestine"). 

(6)  Internal  medication  (rest  and  diet  are  of  no  significance). 
1"  Deutsche  Chirurgie,"  Lief.  46  C,  1905,  p.  604. 


Fig. 


668. — Entero-uterine    and    Enterovag- 
inal Fistula. 
i,  Intestine;   u,  uterus;    /,  /,  fistulae. 


456 


INTESTINAL   SURGERY 


(c)  Operative  (vaginal,  abdominal). 
Vaginal  Operatio?is. — These  are: 

1.  Enterotomy,  after  Dupuytren. 

2.  Suture  of  the  freshened  borders  of  the  fistula. 

3.  Plastic  operations  through  the  vagina. 

4.  Vaginal  extirpation  of  the  segment  of  intestine  containing  the  fistula,  followed 
by  entero-anastomosis  (Brenner). 

5.  Exclusion  of  the  intestine. 

Abdominal  Operations. — 1.  This  route  is  preferable,  assuring  the  best  results. 
If  the  fistula  is  due  to  a  retained  fetus,  a  simple  laparotomy  is  indicated,  with  re- 
moval of  the  necrotic  tissues. 

2.  Lateral  enterorrhaphy;  if  this  is  adopted,  the  vaginal  or  uterine  opening  is 
maintained  for  drainage;   it  closes  later  on. 

3.  Resection  of  the  intestine;  this  is  indicated  where  suture  is  not  possible  without 
inflicting  additional  extensive  injury,  and  where  the  suture  will  cause  a  narrowing 
of  the  lumen. 

4.  Unilateral  enteric  exclusion. 

5.  Bilateral  enteric  exclusion. 

The  following  table  shows  the  results  in  operative  and  non-operative  cases: 


NOX-OPERATKD 

Cases. 

Cases 

Operated  On. 

Variety. 

-6 
a 

o 

13 
1    ID 
S  > 

a 

il 

c  o 

t3 

o 

3 

o 

■6 

3 
O 

il 

Si 

Q 

3 

"o 
El 

Post-operative  fistulae  .... 
Other  fistulae 

11 
15 

12 

i 

2 
20 

13 

48 

3 
12 

1 

3 

6 

3 

22 

Total 

26 

12 

1 

22 

61 

15 

1 

3            6 

25 

(The  mortality  in  these  cases  is  materially  increased  by  the  delay  in  operating,  as 
the  patients  are  often  in  extremis  before  a  systematic,  intelhgent,  and  forceful  efl^ect 
is  made  at  repair.) 

Rectovaginal  Fistula  (Fig.  669). — This  variety  may  be  classified  as  follows: 
Openings  into  the  upper  part  of  the  vagina;  openings  involving  the  middle  portion; 
and,  the  most  common,  those  involving  the  sphincteric  zone. 

These  fistulae  may  be  due  to  several  causes:  Complete  laceration  of  the  perineum 
extending  into  the  vagina  and  rectum;  malignant  disease,  either  of  the  rectum 
or  of  the  vagina  for  cervix),  involving  one  or  the  other  organ  secondarily;  during 
parturition  lack  of  elasticity  of  the  perineal  floor,  use  of  forceps,  craniotribe,  too 
rapid  delivery.  Indifl^erent  gynecologic  work  may  also  give  rise  to  it,  as  may  peri- 
procteal  abscesses,  and  strictures  of  the  rectum  with  infection. 

Symptoms. — The  principal  ones  are  incontinence  of  feces  and  the  escape  through 
the  vagina  of  feces  and  flatus.  The  passage  of  the  feces  causes  a  constant  irritation 
of  the  vagina  and  vulva-     In  rare  cases  there  may  be  an  inversion  of  the  wall  of  the 


FISTULA. 


457 


rectum  and  a  protrusion  of  the  same  through  the  fistula.  Tumors  or  other  organs 
may  also  protrude  through  the  fistulous  opening;  for  instance,  Breisky  had  under 
observation  a  fistula  high  up  with 
a  dermoid  protruding  through  the 
opening. 

The  diagnosis  of  a  rectovag- 
inal fistula  is  always  simple. 
The  opening  may  be  detected, 
either  by  digital  examination, 
rectal  and  vaginal  combined,  or 
by  the  use  of  the  speculum  or 
proctoscope. 

T  r  eat  men  t. — The  following 
methods  of  operative  treatment 
are  all  applicable:  Tait's^  flap- 
splitting  operation,  Emmet's^ 
method  of  repair  of  the  perineum, 
Fritsch's,^  Bureau  and  Vignard's, 
and  Simon's  method. 

Fritsch's  flap-shding  method 
consists  of  an  incision  in  the  vag- 
inal wall,  the  convexity  touching 
the  upper  margin  of  the  fistula. 
The  ends  of  this  incision  are  united  by  a  second  one,  extending  o  inch  below  the 
fistula.  The  vaginal  flap  is  dissected  and  the  ends  of  the  denuded  area  approximated. 

In  Bureau  and  Vignard's  method  a  vertical 
incision  is  made  on  the  posterior  wall  of  the  vagina, 
I  inch  above  and  below  the  fistula.  The  vaginal 
wall  is  dissected  up  from  the  rectal  wall  h,  inch  from 
the  opening.  The  edges  of  the  rectum  are  approxi- 
mated with  catgut.  Relaxation  sutures  are  inserted 
between  the  rectum  and  the  vagina,  the  vaginal 
edges  are  approximated,  and  finally  the  tension- 
relieving  sutures  are  tied. 

Fistulse  high  up  between  the  rectum  and  vagina 
are  treated  on  the  same  plan  as  the  vesico-recto- 
vaginal  fistula  just  described.  Care  must  be  taken 
to  make  extensive  resection  of  the  cicatricial  and. 
infiltrated  tissues;  the  rectovaginal  wall  is  then 
liberated  for  ^  or  ^  inch  all  around  the  opening,  and  a  double  row  of  extramucous 
^  Tait,  L.:    "A  Note  on  Twenty-seven  Cases  of  Perineorrhaphy,"   Brit.   Med.   Jour.,  18S5, 

^  Emmet,  T.  A.:  "Principles  and  Practice  of  Gynecology,"  Phila.,  1884. 
^  Fritsch,  H.:   Loo.  cit. 


Fig.  669. — Rectovaginal  Fistula, 
r,  Rectum;  u,  uterus;  f,  fistula;  v,  vagina. 


Fig.  670. — Showing  Double  Row  of 
Sutures  from  Vaginal  Side  in 
Repair  of  Rectovaginal  Fistula. 


458  IXTESTIXAL    SURGERY. 

sutures  should  be  inserted  from  the  vaginal  side  of  the  rectal  wall  (Fig.  670).  These 
may  be  of  kangaroo  tendon,  silkworm-gut,  or  fine  catgut,  securing  the  upper  end  of 
the'  suture  by  a  knot  or  gutta-percha  plug,  while  the  lower  end  is  fastened  with 
lead  plates,  thus  producing  a  rectal  entropion  of  the  cut  edges.  The  vaginal  wall 
may  be  closed  with  a  whip  stitch  of  fine  silkworm-gut,  securing  the  first  stitch  by  a 
plug  of  gutta-percha.     A  procteal  tube  should  be  inserted  after  all  operations  for 

rectal  fistula. 

The  second  class  of  fistulse  can  be  treated  by  the  same  technic.  It  is  easier  here, 
however,  to  make  an  extensive  separation  upward  of  the  rectovaginal  wall.  If  the 
fistula  is  such  as  to  leave  a  small  band  of  tissue  at  the  sphincter,  it  should  be  di\-ided 
and  transformed  into  a  complete  perineal  laceration.  Where  the  laceration  does  not 
extend  more  than  an  inch  and  a  half  above  the  spliincter,  the  best  method  of  repair 
is  not  a  longitudinal  suture  of  the  rectum,  but  the  hberation  of  the  anterior  rectal 
wall  for  from  2  to  3  inches  above  the  fistula,  then  shding  it  down  to  the  sphincter. 
Once  the  rectum  is  attached  to  the  skin,  the  sphincter  can  be  re-established  by  buried 
sutures,  and  the  vaginal  wall  repaired  either  by  deep  continuous,  interrupted,  or 
leaded  stitches  after  the  usual  methods  of  perineal  repair.  While  this  is  slow  of 
apphcation,  its  significance  and  importance  in  repair  of  rectovaginal  fistula  and  com- 
plete perineal  laceration  are  not  suflaciently  appreciated  by  the  average  operator. 
Unabsorbable  sutures  should  not  be  used.  Unabsorbable  continuous  sutures  may 
be  used,  however,  if  the  distal  end  can  be  readily  reached  when  its  removal  is 
demanded.  The  most  common  cause  of  failure  in  rectovaginal  and  vesicovaginal 
fistula  is  insufficient  excision  of  the  cicatricial  tissue  and  deficient  hberation  of  the 
mucous  margins  of  the  opening.  (As  this  chapter  does  not  include  lacerations  of 
the  perineum,  the  technic  of  repair  of  the  third  division  has  been  omitted.) 

Post-rectal  Fistulae;  Cysts;  Congenital  Fistulae.— These  require  special 
mention  in  connection  with  the  embryonal  remnants  of  the  neuro-enteric  canal,  or 
fistula  resulting  from  suppuration  of  post-rectal  dermoids.  The  post-rectal  cysts 
and  congenital  post-procteal  fistulae  are  the  results  of  failure  of  embryonal  occlusion 
of  the  neuro-enteric  canal.  There  may  be  simple  pilonidal  cutaneous  involucra 
(dermonidal  cysts).  Again,  there  may  be  post-procteal  dermoid  pockets  com- 
municating with  the  rectum  (mucous  exclusion),  or  a  fistula  may  lead  from  the  skin 
to  the  mucosa  of  the  bowel. 

The  variety  which  concerns  us  here  is  the  post-rectal  fistula  communicating  with 
an  epitheUum-lined  pocket  behind  the  rectum.  A  retrorectal  dermoid  may  become 
infected  and  rupture  into  the  rectum,  discharging  pus  and  dermoid  debris  for  months 
and  even  years.  A  sinus  or  opening  in  the  post-rectal  region  discharging  pus,  hair, 
or  debris  would,  of  course,  lead  to  a  diagnosis,  but  the  surgeon  rarely  sees  the  case 
in  this  condition-.  He  finds  merely  an  opening  leading  to  a  suppurating  pocket,  or 
the  patient  complains  of  a  discharge  of  pus  from  the  bowel.  It  may  be  difficult  to 
locate  the  opening.  However,  the  post-procteal  infection  may  be  detected  and  the 
pathology  at  once  suspected. 

The  affected  parts  may  be  reached  by  a  sacro-iliac  incision  close  to  the  margin 


FISTULA. 


459 


of  the  sacrum  and  coccyx,  or  by  a  Kraske^  incision.  By  reflecting  the  bony  flap,  the 
wall  of  the  sac  can  be  freed  from  all  of  its  attachments,  severed  from  the  rectum,  and 
removed.  The  space  should  be  closed  at  once  with  catgut  sutures.  Cysts  should 
be  detached  from  the  rectum  and  the  infiltrated  zone  removed  with  them.  A  mural 
and  extra-mural  double  row  of  absorbable  sutures  should  be  used  to  close  the  rec- 
tum; the  bony  flap  is  then  replaced  and  the  post-procteal  space  drained.  A  large 
permanent  rectal  drainage-tube  is  then  fixed  in  position.  This  class  of  fistulas  is  gen- 
erally mistreated,  since  neither  drainage  nor  cauterization  can  effect  a  cure;  as  the 
cavity  is  lined  with  epithelial  cells  and  essentially  a  muco-cutaneous  cavity,  excision 
of  the  fistula  or  sac  is  the  only  means  of  radical  cure.     If  the  dermoid  is  inflamed 


FiQ.    671. — Multiple    Entero-intestinal     Stric- 
tures OF  Tuberculous  Origin   (Caird). 
a,  a,  Fistulous  opening. 

or  infected  before  the  rectal  communication  is  established,  it  should  not  be  drained, 
but  extirpated  by  trans-sacral  or  para-sacral  incision. 

Infected  pilonidal  cysts  do  not  belong  in  gynecologic  work,  but  they  are  so  closely 
related  to  the  post-rectal  infected  dermoid  that  a  word  is  necessary.  A  complete 
excision  of  the  epithelium-lined  cavity  is  the  only  means  of  radical  cure,  even  though 
a  portion  of  the  rectum  has  to  be  sacrificed.  Such  cysts  and  fistulse  should  never  be 
cureted  or  injected.  Post-procteal  dermoids  may  attain  a  size  sufficient  to  displace 
all  the  pelvic  organs  above  a  line  from  the  symphysis  to  the  promontory,  as  observed 
in  a  case  operated  on  recently  by  the  writer. 

Entero-intestinal  fistulae  are  not  at  all  uncommon.  They  occur  chiefly  in  the 
pelvis  and  are  often  associated  with  one  of  the  other  forms  of  fistula  mentioned 
above.  If  few  in  number  they  should  be  separated  and  the  openings  closed  with 
a  Czerny-Lembert  suture.     If  multiple  (see  Fig.  671)  and  within  a  circumscribed 

^  Kraske,  Paul:  "Erfahrungen  iiber  den  Mastdarmkrebs,"  Volkmann's  klin.  Vortr.,  1897, 
No.  183-184 


460  INTESTINAL   SURGERY. 

zone,  excision  of  the  agglutinated  and  fistulous  mass  should  be  made.  When 
tuberculous,  excision  of  the  entire  tuberculous  zone  is  the  only  treatment  that  avails. 
In  tuberculosis,  if  excision  is  not  feasible,  then  the  agglutinated  coil  should  not  be 
distended.  Occasionally  there  is  a  gastro-colonic  or  gastro-intestinal  fistula  the 
result  of  pathologic  conditions,  most  commonly  primary,  in  the  stomach. 


POST-OPERATIVE  INTESTINAL  ADHESIONS. 

These  are  the  greatest  evils  of  abdominal  or  vaginal  surgery,  and  the  most 
annoying  to  the  patient.  Post-operative  adhesions  are  the  principal  factors  of  the 
chronic  invahdism  in  women  after  operation.  Sometimes  brilliant  results  in  the 
removal  of  a  diseased  organ  are  nulHfied  by  these  adhesions.  Frequently,  the  writer 
is  sorry  to  admit,  women  operated  on  for  insignificant  pelvic  troubles  become  chronic 
invaHds,  and  are  in  a  more  serious  condition  than  before  the  operation.  Therefore, 
the  knowledge  of  this  evil  and  the  means  by  which  it  can  be  prevented  are  indeed  the 
greatest  problems  which  present  themselves  in  abdominal  and  gynecologic  surgery. 

Etiology. — The  most  common  causes  of  adhesions  are  abrasions  or  exposed  sur- 
faces, such  as  pedicles,  denuded  peritoneal  areas,  separated  adhesions,  etc.  Malig- 
nant tumors  of  the  uterus,  with  their  characteristic  tendency  to  involve  surrounding 
organs,  are  frequently  responsible  for  the  production  of  adhesions,  and  the  greatest 
skill  often  cannot  avoid  injury  or  abrasions  of  the  peritoneum.  Infection  of  the 
pelvic  organs  with  plastic  exudates  on  the  omentum,  peritoneum,  or  coils  of  intestine, 
form  adhesions  previous  to  the  time  of  operation,  and  at  the  time  of  intervention  the 
destruction  of  these  adhesions,  no  matter  how  carefully  done,  constitutes  the  common 
etiologic  factor  of  post-operative  adhesions.  Ovarian  cysts  and  those  in  the  broad 
Hgament,  or  infected  dermoids,  may  become  adherent  to  the  intestines.  Peritoneal 
drainage  is,  in  many  cases,  the  cause  of  adhesions.  Gauze  drainage  is  particularly 
potent.  The  pelvic  organs  may  become  adherent  to  each  other,  to  the  drain,  or  to 
the  neighboring  coils  of  intestine.  Capillary  drainage  is  undoubtedly  responsible 
for  many  adhesions.  Glass  or  rubber  tubes,  while  producing  some  irritation,  are 
less  prone  to  give  rise  to  adhesions.  The  surface  of  these  tubes  is  smooth  and  the 
space  occupied  is  very  limited. 

Pelvic  hemorrhage  during  operation,  or  oozing  after  the  closure  of  the  abdominal 
wound,  produces  hematomata  which  when  absorbed  result  in  organic  adhesions. 
The  blood-clots  with  their  fibrin  in  the  process  of  absorption  produce  granulation 
tissue  which  leads  to  adhesions  in  the  same  manner  as  the  capillary  drainage.  For 
this  reason  perfect  hemostasis  will  not  only  prevent  loss  of  blood  and  shock,  but  will 
also  act  as  a  prophylactic  against  adhesions. 

Cauterization. — The  use  of  the  cautery  to  arrest  hemorrhage  or  to  sterilize 
abraded  surfaces  or  infected  pedicles,  etc.,  will  predispose  the  abraded  surfaces  to 
infection  and  consequently  to  adhesions.  K.  Franz  has  carried  out  many  experi- 
ments on  dogs,  and  after  careful  investigation  concludes  that  perfectly  aseptic 
abrasions  do  not  form  definitive  adhesions.     The  writer  is  of  the  opinion  that  the 


POST-OPERATIVE   INTESTINAL   ADHESIONS. 


461 


cautery  should  be  used  only  in  extreme  cases,  where  the  hemorrhage  cannot  be 
otherwise  controlled.  As  stated  previously,  handUng  of  the  intestine  increases  the 
chances  for  adhesions.  Too  long  exposure  to  the  air,  especially  if  dry,  has  the  same 
tendency.     Undue  use  of  retractors  is  also  a  predisposing  cause. 

Finally,  some  patients  exhibit  individual  tendencies  to  adhesions  and  fibrous 
keloid  formations  in  the  peritoneum.  For  instance,  one  of  my  patients,  followmg 
an  intermediate  appendectomy  developed  adhesions,  for  which  I  subsequently  per- 
formed fourteen  laparotomies.  The  patient  could  locate  the  adhesion,  which  was 
always  small,  distinctly  after  each  succeeding  operation.     Cure  was  finally  obtained, 

however. 

Symptoms.— Pain  and  dragging  sensations  are  the  principal  symptoms  announc- 
ing the  presence  of  adhesions.  If  soon  after  an  operation  for  pelvic  trouble  the 
patient  complains  of  pain  when  there  is  no  obvious  reason  for  it,  we  should  at  once 
suspect  adhesions  as  the  cause.  The  pain  may  be  as  severe  as,  or  even  more  so  than, 
the  pre-operative  pain. 

Patients  leave  the  hospital  with  cramp-Uke  pains,  which  may  continue  for  months 
and  then  disappear  if  the  pelvic  exudate  has  been  absorbed,  or  if  the  latter  has  become 
organized  and  firmly  adherent  the  pain  will  never  cease.  It  is  a  different  pain  from 
the  original;  it  is  usually  induced  or  exaggerated  by  exercise.  It  is  dragging  in 
character,  indicating  that  the  intestine  or  omentum  is  under  traction.  The  adhesions 
between  the  intestine  and  pelvic  organs  may  manifest  themselves  either  as  intestinal 
symptoms  or  as  symptoms  referable  to  the  pelvic  organs .  If  the  intestine  has  become 
adherent  and  is  under  traction,  the  immobihzation  of  a  segment  of  bowel  will 
interfere  with  peristalsis,  consequently  the  main  symptom  will  be  coprostasis.  If  a 
band  of  adhesions  crosses  the  intestine,  it  may  produce  intermittent  and  incom- 
plete obstruction.  Adhesions  of  the  pelvic  organs  may  simulate  ovaritis,  salpingitis, 
endometritis,  etc.  Vaginal  pains  and  bearing-down  sensations  are  indicative  of  ad- 
hesions between  the  intestine  and  the  wall  of  the  vagina  after  vaginal  surgery.  ^  If 
the  bladder  is  the  adherent  organ,  then  the  patient  has  derangement  of  micturition. 
If  the  intestine  is  adherent  to  the  abdominal  wall,  the  pain  is  superficial.  The 
stomach  rarely  becomes  adherent  to  the  abdominal  walls  except  in  pyloroplasties 
or  anterior  gastrotomies;  such  cases  have,  however,  been  observed  by  the  writer,  as 
well  as  by  others.  The  surgeon  will  occasionally  examine  a  patient  with  gastric 
symptoms  following  a  pelvic  operation,  and  before  opening  the  abdomen  may  be 
unable  to  determine  their  etiology,  especially  in  the  presence  of  negative  findings 
of  gastric  contents  and  motility.  Ten  years  after  a  double  oophorectomy  the  writer 
found  the  pyloric  zone  firmly  adherent  to  the  left  ovarian  stump. 

Pathology.— The  intestines  may  become  adherent  to  the  abdominal  or  vaginal 
incisions.  Coils  may  become  adherent  to  each  other  and  to  the  surrounding  ab- 
dominal or  pelvic  organs.  In  order  of  frequency  of  post-operative  adhesions,  the 
writer  would  indicate  them  as  follows:  Omentum,  sigmoid,  small  intestine,  rectum. 

Omentum.— On  account  of  the  anatomic  position  of  the  omentum  it  can  be  seen 
that  it  may  touch  almost  every  organ  within  the  peritoneum,  including  the  pelvic 


462  INTESTINAL    SURGERY. 

floor.  Its  greatest  functions,  from  a  surgical  standpoint,  are  to  produce  abdominal 
lymphocytosis,  circumscribe  infected  zones,  and  cover  abraded  surfaces. 

Sigmoid:— TlAs  organ  is  frequently  bound  in  pelvic  adhesions.  This  is,  of 
course,  easily  explained  by  its  proximity  to  the  pelvic  organs.  The  adhesion  of  the 
sigmoid  to  the  pelvic  infected  zones  is  often  a  fortunate  occurrence,  as  it  protects  the 
general  peritoneal  cavity  from  infection.  It  is  the  gynecologist's  greatest  friend, 
and  to  him  plays  the  same  role  as  the  omentum  does  to  the  general  surgeon.  The 
appendices  epiploicse  rapidly  rally  to  the  encapsulation  of  pelvic  infection  and  to  the 
sealing  of  pelvic  abrasions. 

Small  Intestine. — Adhesions  of  the  lower  and  upper  segments  are  very  common. 
When  they  involve  the  lower  part  of  the  ileum  the  patient  experiences  little  pain. 
When  adhesions  occur  between  the  pelvic  organs  and  the  upper  ileum,  considerable 
traction  is  exerted,  and  much  pain  ensues.  The  pelvic  organs  frequently  become 
infected,  produce  abscesses  which  rupture  into  the  intestine,  and  result  in  temporary 
or  permanent  fistulse.  In  a  recent  case  examined  by  me  one  year  after  an  oophorec- 
tomy, in  which  a  heavy  silk  ligature  was  used,  I  found  an  adhesion  between  the  upper 
jejunum  and  the  stump.  The  patient  had  complained  for  the  twelve  months  of  a 
dragging  pain  in  the  left  side,  which  was  greatly  increased  after  exertion  and  on  as- 
suming the  upright  position. 

Intestinal  adhesions  may  be  single  or  multiple.  I  had  occasion  to  remove 
in  an  individual  case  no  less  than  fourteen  separate  and  distinct  coil  adhesions  from  a 
pelvic  infection  focus. 

Rectum. — Exudates  and  infiltrations,  primary  and  secondary,  and  peri-procteal 
infections  produce  either  traction  on  the  walls  of  the  rectum  or  compression  of  the 
same  by  formation  of  fibrous  tissue.  Sometimes  the  traction  may  be  so  great  as  to 
form  a  false  diverticulum. 

Urinary  Organs. — The  ureter  rarely  becomes  adherent  to  the  intestine.  Cica- 
tricial tissue  will  sometimes  surround  the  ureteral  tube  and  constrict  it  from  the  out- 
side. In  the  course  of  time  this  may  be  responsible  for  hydronephrosis.  Ad- 
hesions between  the  ureter  and  the  intestine  are  caused  most  frequently  by  the  re- 
moval of  subperitoneal  cysts.  The  fundus  of  the  bladder  may  become  adherent  to 
the  intestine,  and  as  the  bladder  is  more  firmly  fixed  than  the  intestine,  the  latter 
will  be  subjected  to  traction.  Frequent  micturition  combined  with  intestinal  symp- 
toms will  constitute  the  cHnical  picture  of  such  a  case. 

Prophylaxis. — To  obtain  a  clear  idea  of  how  post-operative  adhesions  may  be 
prevented  it  is  necessary  to  mention  the  principal  etiologic  factors,  which  are  abra- 
sions and  infections. 

The  technic  for  prophylaxis  of  adhesions  is  as  follows: 

1.  A  fold  of  the  loose  peritoneum  in  the  neighborhood  is  used  to  cover  the  abraded 
surfaces  and  should  be  stayed  with  absorbable  sutures. 

2.  Involution  of  the  abraded  surfaces  is  the  routine  protective  management  of 
the  appendix,  mesovarium,  mesosalpinx,  or  other  stumps. 

3.  Covering  the  abraded  surfaces  by  neighboring  peritoneal  covered  organs,  in 


POST-OPERATIVE    INTESTINAL   ADHESIONS. 


463 


such  a  manner  as  not  to  compromise  the  motility  or  function  of  the  transplanted 
organ  by  traction.  It  has  been  my  practice  for  years  to  transplant  the  sigmoid  over 
pelvic  abrasions.  Occasionally  I  appropriate  the  uterus  to  cover  rectal  abrasions 
and  fistulse. 

4.  Peritoneoplasty. — By  this  is  meant  the  covering  of  abraded  areas  by  perito- 
neum, for  the  purpose  of  rendering  abdominal  organs  extraperitoneal.  This  origin- 
ated with  Martin,  of  Berhn.  It  was  also  recommended  by  several  other  authors, 
among  them  Sneguireff,  who  termed  it  "  autoplasty." 

Amann  advises  the  reconstruction  of  the  pelvic  peri- 
toneal floor  by  immobilizing  or  transplanting  neigh- 
boring peritoneum,  or  by  transplanting  organs 
covered  with  peritoneum  at  the  denuded  area;  these 
must  be  free  from  traction.  Loewy  advises  graft- 
ing of  peritoneum  or  mesentery  upon  the  abraded 
areas.  The  peritoneum  is  so  loosely  attached  in 
many  places  that  large  flaps  can  be  transplanted 
with  great  ease.  The  pedicle  of  the  flap  has  great 
vitality  and  its  life  is  assured.  In  cases  of  pelvic 
infection  where  exclusion  from  the  peritoneal  cavity 
is  desired,  it  can  be  done  by  sliding  the  loose  fold 
of  peritoneum  over  the  injured  surface  by  displac- 
ing the  anterior  fold  of  the  broad  ligament,  which 
can  be  readily  slipped  backward  and  the  infected 
zone  excluded. 

5.  Ectropion  of  the  Peritoneum. — By  this  we  un- 
derstand the  eversion  of  the  cut  edges  of  the  peri- 
toneum along  the  line  of  the  abdominal  incision, 
which  is  effected  by  a  line  of  continuous  sutures  \ 
inch  from  the  cut  edge,  so  that  the  union  is  accom- 
plished between  two  lateral  peritoneal  surfaces, 
thus  excluding  the  raw  edges  from  the  peritoneal 
cavity  and  avoiding  post-operative  adhesions  at  the 
line  of  incision.  In  the  past  ten  years  I  have  had 
occasion  to  open  the  abdomens  of  patients  pre- 
viously closed  by  this  method,  and  I  failed  to  see 

either  adhesions  between  the  omentum  and  the  abdominal  scar,  or  between  the 
latter  and  the  intestine.  The  method  is  very  simple  and  can  be  highly  recom- 
mended. 

6.  Prophylaxis  by  Position. — In  the  event  of  enteroptosis  or  gastroptosis,  where 
the  organs  come  in  immediate  contact  with  the  infected  parts  of  the  pelvis,  and  where 
we  are  unable  to  cover  the  abraded  peritoneal  areas,  the  post-operative  position  of 
the  patient  can  be  used  to  advantage.  During  the  operation  the  patient  is  kept  in 
the  Trendelenburg  position;   when  returned  to  bed  she  is  kept  in  an  exaggerated 


Fig.  672. — Continuous  Catgut  Suture 
Passed  in  such  a  Manner  as  to 
Produce  an  Ectropion  of  the 
Cut  Edges  of  Peritoneum. 


464  INTESTINAL   SURGERY. 

Sims  position  with  the  buttocks  elevated,  which  tends  to  displace  the  intestines  out 
of  the  pelvis  and  diaphragmward  during  the  process  of  repair. 

Distention  of  Abdominal  Cavity  by  Artificial  Means.— The  intestines  may 
be  separated  from  each  other  or  from  the  pelvic  organs  and  the  abdominal  wall  in 
several  ways.  Normal  salt  solution,  filtered  air,  and  nitrogen  are  the  means  most 
commonly  used. 

Anterior  fixation  is  avoided  by  distention  of  the  abdomen  with  nitrogen  gas  or 
filtered  air,  which  is  easily  carried  out  as  follows:  Before  closing  the  abdomen  a 
hollow  needle  is  inserted  in  the  lower  angle  of  the  abdominal  wound.  The  perito- 
neum is  sutured  around  the  needle  and  the  remaining  abdominal  layers  are  com- 
pletely closed.  From  100  to  150  cubic  inches  of  nitrogen  are  injected  under  a  3- 
pound  pressure  from  a  tank  through  this  needle  into  the  peritoneal  cavity  until  firm 
distention  of  the  abdominal  walls  is  secured.  The  needle  is  then  withdrawn  and  the 
patient  placed  in  the  recumbent  position.  This  vaults  up  the  anterior  abdominal 
wall  and  prevents  contact  with  the  intestines,  which  are  held  by  the  mesentery  and 
gravitate  to  the  posterior  wall.  The  exaggerated  Sims  position  will  prevent  ad- 
hesions in  the  pelvis,  and  the  Fowler  in  the  upper  abdomen.  It  requires  about  three 
or  four  weeks  for  complete  absorption  of  the  gas.  In  the  meantime  endothehal 
or  connective  tissue  covers  the  abrasions.  I  do  not  know  that  nitrogen  is  superior 
to  filtered  air,  but  from  the  experience  we  have  gained  in  more  than  1600  cases  of 
injection  of  nitrogen  into  the  pleura  without  a  single  infection,  I  consider  the  use  of 
nitrogen  safer.  Perfect  filtration  and  sterilization  of  air  is  by  no  means  an  easy 
procedure.     Both  can  be  injected  through  the  ordinary  oxygen  inhaler. 

Separatmn  of  Adhesions. — When  we  encounter  extensive  omental  adhesions  to 
fixed  structures,  they  should  not  be  torn.  It  is  better  to  ligate  the  omentum  above 
the  point  of  adhesion  and  allow  the  stump  to  retract,  leaving  the  adherent  omentum 
as  a  flap  over  the  destroyed  peritoneal  surface.  In  this  case  the  omentum  may  be 
cut  straight  across,  and  ligated  at  any  point  above  the  umbilical  level.  The  life 
of  the  flap  is  assured  by  the  collateral  circulation,  and  by  allowing  it  to  remain  we 
avoid  the  necessity — and  in  many  cases  the  impossibility — of  covering  abraded  sur- 
faces. If  the  omentum  is  adherent  to  pus-tubes  or  ovary,  or  to  any  portion  of  an  in- 
fected pelvic  floor,  the  adhesions  can  be  carefully  removed  with  dry  gauze  or  sponges. 
The  sponge  is  wrapped  around  the  finger  and  the  adherent  surface  gently  rubbed 
until  it  becomes  detached.  If  the  stump  is  adherent  to  the  pelvic  floor,  the  separa- 
tion can  be  accomplished  by  dry  gauze  and  gentle  manipulation.  The  abraded  sur- 
face of  the  stump  may  be  covered  by  an  omental  flap  or  by  peritoneal  plication. 
The  separation  of  the  intestine,  in  case  of  adhesion  to  the  abdominal  scar,  can  be  ac- 
complished in  the  same  manner.  The  abraded  surface  of  the  intestine  can  be  covered 
by  rolling  it  on  its  mesentery  and  fixing  it  by  sutures.  Entero-enteric  adhesions 
should  not  be  disturbed  unless  angulation  or  traction  is  present.  Cauterization  of 
the  surfaces  after  separation  of  the  adhesions  is  not  advisable,  and  should  be  resorted 
to  only  in  extreme  cases.  In  separating  adhesions  or  scars  of  ancient  suppurative 
pockets  the  union  is  organic,  and  in  the  endeavor  to  free  the  intestines  from  such  poc- 


POST-OPERATIVE    INTESTINAL   ADHESIONS.  465 

kets  they  may  be  torn.  Not  infrequently,  in  separating  the  adherent  types  from  the 
small  and  particularly  the  large  intestine,  one  finds  a  fistula  leading  from  one  mucous 
cavity  to  another,  or  a  communication  between  the  intestinal  lumen  and  an  in- 
fected dermoid.     (The  management  of  this  class  of  cases  is  treated  of  under  Fistulse.) 

In  separating  intestinal  adhesions  from  ovarian  cysts,  an  incision  should  be  made 
into  the  outer  layer  of  the  cyst  wall,  and  a  thin  layer  allowed  to  remain  adherent  to 
the  intestine.  This  is  a  better  procedure  than  complete  separation  from  the  in- 
testine, as  the  latter  might  be  injured  in  the  attempt.  The  oozing  from  an  abraded 
surface  can  be  readily  controlled  by  sponges,  pressure,  or  hot  air  cauterization. 
After  vaginal  hysterectomy  the  small  intestine  may  prolapse  into  the  vagina  and 
become  adherent  to  the  wound  margins.  The  separation  of  such  adhesions  is  very 
difficult  and  often  impossible.  If  6  to  8  inches  of  bowel  are  thus  compromised,  the 
safest  and  most  expedient  method  is  suprapubic  resection  of  the  adherent  segment 
and  end-to-end  union.  Occasionally  a  coil  of  intestine  is  so  fixed  that  it  cannot  be 
liberated  without  dangerous  prolongation  of  time  and  great  trauma  to  the  wall.  In 
this  event  intestinal  exclusion  is  the  most  desirable  method  of  management.  Drain- 
age is  established,  and  after  the  infective  process  has  subsided,  the  excluded  coil  can 
be  safely  extirpated. 

When  enterovesical  adhesions  are  difficult  to  separate,  it  is  advisable  to  leave  a 
portion  of  the  muscularis  vesicae  adherent  to  the  intestine,  and  repair  the  abraded 
surface  of  the  former. 

Infected  tumors  and  cysts;  pelvic  abscesses  opening  into  the  rectum; 
infected  ovarian  cysts  (especially  infected  dermoids);  gonorrheal  or  tubercu- 
lous salpingitis,  and  ruptured  ectopic  products,  may  all  adhere  to  the  rectum, 
finally  perforating  it,  and  evacuate  their  contents  into  the  lower  bowel. 

Though  Keen,^  in  his  classic  treatise  on  the  subject,  says  that  typhoid  fever  rarely 
affects  the  internal  genitalia  of  women,  H.  J.  Boldt  observed  and  accurately  reported 
a  case  of  this  type  of  tubal  infection  which  opened  into  the  rectum.  Pyosalpinx 
of  gonorrheal  origin  may  open  into  the  sigmoid  or  into  the  rectum,  though  it  is  rare, 
as  a  simple  gonorrhea  is  seldom  virulent  enough  to  produce  a  tissue  necrosis.  This 
probably  accounts  for  the  infrequency  of  tubo-enteric  fistula. 

Treatment. — The  management  of  infected  cysts,  pyosalpinx,  etc.,  which  open  into 
the  rectum  or  the  sigmoid  is  as  follows : 

1.  Drainage  should  be  free  and  maintained  for  a  certain  length  of  time  to  reduce 
the  virulence  of  the  infection,  also  to  increase  the  local  immunity. 

2.  Removal  of  the  necrotic  tissue  of  the  tumor,  or  of  the  infected  tube. 

In  the  case  of  an  infected  or  necrotic  myoma  or  infected  ectopic  gestation,  the 
wall  need  not  necessarily  be  removed,  as  it  is  not  epithelium-lined  and  will  close  when 
the  debris  is  removed.  The  course  to  be  pursued  is  entirely  different  when  we  are 
confronted  with  an  infected  ovarian  dermoid  or  a  salpinx,  both  of  which  are  lined  with 
epithelium.  The  lining  of  these  cysts  must  be  removed,  as  agglutination  or  oblitera- 
tion of  the  walls  will  never  be  attained,  unless  it  is  completely  extirpated.     The  same 

^Keen,  W.  W.:  "Surg.  Compl.  and  Sequels  of  Typhoid  Fever,"  Philadelphia,  1898. 
VOL.  II — 30 


466  INTESTINAL   SURGERY. 

may  be  said  of  a  tube  with  gonorrheal  infection.  The  fimbriated  end  is  sealed  by 
adhesions,  the  uterine  end  closed  by  a  gonorrheal  stricture  and  the  intervening  mu- 
cosa infected.  Ablation  of  the  mucous  tube  is  the  only  means  of  effecting  a  per- 
manent cure. 

The  intestinal  opening  should  be  closed  by  a  double  row  of  Pagenstecher  Hnen 
sutures.  Prolonged  drainage  is  not  justifiable,  as  the  absorption  from  the  infected 
dermoid  surface  is  great,  and  will  give  rise  to  grave  general  sepsis.  Furthermore,  it 
is  of  no  advantage,  since  it  never  leads  to  repair  if  the  epithelial  lining  has  not  been 
destroyed. 

Often  in  cystic  infections  the  ablation  of  the  inner  wall  (its  epithelial  lining)  may 
be  effected  without  removing  the  outer  cyst  wall,  as  such  procedure  avoids  the 
possibility  of  injuring  neighboring  adherent  viscera  and  leaves  a  surface  that  has 
htde,  if  any,  absorptive  power;  there  is  therefore  no  danger  of  infection. 

Relationship  between  Pelvic  Infections,  Rectal  Infections,  Rectal  and 
Perirectal  Tissues.— Infections  of  the  broad  ligaments— post-abortum  and  post- 
parturient— not  infrequently  extend  to  the  periprocteal  connective  tissue.  This  is  at 
first  infiltrated  and  becomes  necrotic  and  finally  is  transformed  into  an  abscess,  which 
should  be  drained  as  soon  as  it  is  recognized.  After  drainage  there  is  contraction 
of  the  connective  tissue,  forming  a  perirectal  constriction.  These  cases  are  very 
difficult  to  treat,  as  all  the  neighboring  structures  are  involved,  and  drawn  closely 
around  the  rectum.  In  the  treatment  of  this  type  of  stricture  massage  and  the 
bougie  are  more  effective  than  operation. 

After  operation  upon  the  broad  ligaments  the  periprocteal  tissue  may  be  in- 
filtrated with  blood,  giving  rise  to  what  is  known  as  "retro-uterine"  or  "periprocteal 
hematocele."  After  the  absorption  of  the  blood  a  stricture  is  occasionally  produced, 
which  calls  for  the  same  treatment. 


EXAMINATIONS  OF  RECTUM  AND  SIGMOID. 

These  may  be  divided  into  palpation — (a)  internal,  (b)  external;  distention — 
(a)  gaseous,  (b)  fluid;  inspection. 

Internal  palpation  is  of  value  in  the  lower  4  inches  of  the  rectum  only.  It  may  be 
accomplished  through  the  vagina  in  the  female  and  through  the  rectum  in  the  male. 
In  irritations,  fissures,  and  inflamed  hemorrhoids  either  a  local  or  a  general  anesthe- 
tic should  be  resorted  to.  Often  an  anal  lesion  is  associated  with  an  ulceration, 
tumor,  or  stricture  higher  up;  the  upper  lesions  are  frequently  overlooked  and  all 
of  the  symptoms  attributed  to  the  lower  lesion. 

External  palpation  of  the  sigmoid  and  rectum  very  often  reveals  the  circumscribed 
inflammatory  mass  of  the  intramural  or  perisigmoidal  infected  sinuses,  the  induration, 
nodular  and  woody,  resistance  of  a  carcinoma,  or  the  hard,  cord-like,  knotty  mass  of 
a  tuberculosis.  Distention  above  the  point  of  obstruction  can  often  be  outlined 
by  a  careful  palpation. 

Gaseous  distention  of  the  rectum  and  colon  often  reveals  the  point  of  obstruction 


EXAMINATION    OF    RECTUM   AND    SIGMOID. 


467 


or  fixation,  and  is  valuable  in  outlining  the  relation  of  the  colon  to  abdominal 
neoplasms. 

Fluid  distention  often  reveals  obstructions  or  malpositions,  and  has  the  advan- 
tage of  the  flat  percussion  note  to  more  certainly  indicate  the  intestinal  position. 


Fig.  673. — Murphy's  Telescoping  Proctoscopes.     Rectal  Speculum  on  Lower  P.i.rt  of  Illustration. 


Inspection  is  best  accomplished  with  the  telescoping  proctoscope,  which  I  have 
devised  for  this  purpose  (Fig.  673).  The  shorter  instrument  and  the  one  of  largest 
diameter  permits  of  a  close  inspection  of  the  lower  4  inches  of  the  rectum.  The  next 
larger  size  is  passed  into  this,  and  without  withdrawing  it  each  additional  larger  one 
is  introduced  in  succession  until  the  longest  sigmoidoscope  (14  inches)  is  inserted. 


468 


INTESTINAL    SURGERY. 


In  this  way  the  patient  suffers  no  pain  from  the  additional  introductions  and  a 
careful  inspection  can  be  made  of  every  inch  of  the  field.  The  surface  should  be 
carefully  sponged  from  time  to  time,  as  fecal  deposits  not  infrequently  resemble 
superficial  ulcers.  The  character  of  the  lesion  can  be  very  well  determined  by  close 
and  careful  inspection.  The  electric  instrument  is  not  as  reliable  as  the  reflected 
light.  A  long  snare  may  be  used  through  the  proctoscope  for  the  removaJ  of  polypi 
and  fragments  of  tumor  may  be  obtained  for  microscopic  examination. 


c^\ 


MALFORMATIONS  OF  THE  ANUS  AND  RECTUM. 
The  ano-r,ectal  region  is  the  seat  of  several  varieties  of  occlusion.     These  may  be 
conveniently  divided  into  two  groups :  occlusions  of  the  anus  and  of  the  rectum. 

The  anus  may  be 
abnormally  narrow, 
due  to  the  skin  or 
muscle  being  stretched 
across  the  opening. 
The  stenosis  is  gener- 
ally near  the  outer  sur- 
face of  the  body,  and 
varies  in  degree  from 
a  slight  narrowing  of 
the  normal  passage  to 
almost  complete  oc- 
clusion. In  a  second 
variety  the  anus  is 
closed  by  a  thin  mem- 
brane through  which 
the  bowel  contents 
may  be  seen  and  felt. 
This  variety  is  very  rare  and  is  easily  remedied.  A  small  pit  in  the  skin,  which 
is  imperforate,  is  no  indication  that  the  lower  end  of  the  rectum  is  near  by;  the 
external  sphincter  is  occasionally  wanting. 

The  rectum  is  developed  from  the  enterodeum — the  hind  end  of  the  primitive 
gut.  The  anus,  on  the  contrary,  is  developed  by  an  infolding  of  the  epiblast — the 
proctodeum.  Normally  the  intervening  septum  disappears  and  free  communication 
is  established. 

The  abnormal  terminations  of  the  bowel  are  classified  as  follows : 
1.  In  some  cases  the  septum  persists  and  the  rectum  ends  in  a  blind  pouch  at  a 
variable  distance — up  to  several  inches — from  the  perineum.  The  rectal  ampulla 
is  generally  to  be  found  near  the  left  sacro-iliac  joint.  The  partition  may  be 
thin,  but  is  usually  thick.  It  is  rarely  perforated,  and  may  be  multiple.  The 
intervening  space  is  filled  with  connective  tissue,  and  in  some  cases  a  fibrous  cord 


Fig.  674. — Total  Absence  of  Rectum  (after  Chalot). 
aci,   Inferior  colic   artery ;    ams,  sigmoid    ampulla;    cm,  mesocolic  cord; 
mesosigmoid  ;    sa,  sacrum. 


MALFORMATIONS    OF   THE   ANUS    AND    RECTUM. 


469 


runs  down  from  the  end  of  the  rectum  (Fig.  675).     If,  as  sometimes  happens,  the 
anus   is   apparently  normal,  diagnosis 
is    obscure     unless    a    thorough     ex- 
amination is  made. 


Fig.  675. — Imperforate  Anus. 
a,  Rectum ;    6,  cul-de-sac  of  the  rectum  ;   c,  the  cord- 
like rudiment  of  the  rectum  ;    d,  sigmoid  flexure. 


Fig.  676. — Appearance  of  Imperforate  Anus,  with 
Rectum  Terminating  in  the  Bladder  (Boden- 
hamer). 

a.  Bladder;  b,  rectum;  c,  neck  of  bladder;  d,  d,  ureters; 
e,  g,  urethra. 


2.  In  40  per  cent.  (Leichtenstern^)  of  the  cases  of  rectal  malformation,  whether 
the  anus  is  present  or  not,  the  rectum  opens  into  some  neighboring  organ. 


Fig.  677. — Showing  an  Imperforate  Anus,   Rectum  Fig.  678. — Rectum    Opening    into    the    Urethra 

Communicating  with  Urethra  (Bodenhamer).  (Bodenhamer). 

a.  Vagina;    b,   6,   ureters;    c,   rectum;     d,  urethra;    e,  a.  Rectum;  b,  bladder;   c,  penis, 

bladder. 


This   abnormal    opening   is    most   commonly   into   the   vagina.     When   it   com- 
municates with  the   urinary  organs,  in   males  it  opens  more  frequently  into  the 

'  Leichtenstern,  O.:   "  Verengerungen,  Verschliessungen  unci  Lageveriinderungen  des  Darms," 
von  Ziemssen's  Handbuch,  1876,  vii,  2,  359. 


470 


INTESTINAL   SURGERY. 


bladder  (Figs.  676,  679,  683);  occasionally  into  the  urethra  (Figs.  677,  678).  In 
females,  on  the  other  hand,  the  opening  is  generally  into  the  urethra  (Fig.  677), 
seldom  into  the  bladder.  This  variety  is  not  incompatible  with  existence,  and 
several  cases  are  recorded  in  both  sexes  where  the  patients  have  reached  adult  life. 


Fig.    680. — Anus    and    Rectum    Separated    by   a    Septum   due   to 
Failure    of    Coalescence  (Bodenhamer). 
a,  The  large  sac-like  opening;  b,  the  point  of  occlusion  of  rectum; 
c,  circular  fibers  of  the  external  sphincter;    d,  normal  anus;    e,  bladder 
small  and  contracted;   /,  the  urethra;   g,  sigmoid  flexure  of  the  colon. 


Fig.  679. — Imperforate  Anus  with 
Rectum      Opening     into      the 
Bladder  (Bodenhamer). 
a,  Rectum;    b,  bladder  laid  open; 
c,  urethra;    d,  penis;     e,  e,  umbilical 
arteries;    /,     umbilical   vein;    g,    liga- 
ment leading  from  the  bladder  to  the 
umbilicus;  h,  urachus  within  the  liga- 
ment;  ?',  rectovesical  opening. 


Fig.  681. — Imperforate    Anus    and    Rectum  with  Distention   of 
Sigmoid  (Bodenhamer). 
o,  Descending  colon;   b,  b,  sac-like  dilatations  of  colon;  c,  bladder, 
behind  which    colon    passes;    d,  e,  the  small   intestine  in  normal  con- 
dition. 


3.  The  anus  being  imperforate,  the  rectum  opens  on  the  skin. 

4.  The  primitive  cloaca  persists  owing  to  non-development  of  the  normal 
septa,  and  the  rectum  and  vagina  end  in  a  common  passage  as  in  some  of  the  lower 


MALFORMATIONS    OF   THE   ANUS    AND    RECTUM. 


471 


animals.     This  variety,  too,  does  not  hazard  Hfe.     In  practically  all  of  these  de- 
formities there  is  enormous  distention  of  the  rectum  and  sigmoid. 

5.  Total  absence  of  the  rectum 
is  rare  (Figs.  674,  685).  In  a  series  of 
four  hundred  and  sixty-five  cases  of 


a  —- L , 


Fig.  682. — Anus  and  Rectum  Separated  by  a  Septum 
DUE  TO  Failure  of  Coalescence  (Bodenhamer). 
a,  Rectum  greatly  distended;    6,  cul-de-sac  of  rec- 
tum at  point  of  occlusion;  c,  sigmoid  flexure  of  colon;  d, 
bladder. 


Fig.     683. — Showing     Rectum     Emptying    into 
THE    Bas    Fond    of   the    Bladder    (Boden- 
hamer). 
a,  Urachus;   &,  rectum;   c,  c,  ureters;  c?,  urethra. 


ano-rectal  malformations  collected  by 
Bodenhamer,^  in  only  forty-one  were 
the  rectum  and  colon  entirely  absent. 

The  symptoms  of  these  occlusions 
naturally  manifest  themselves  soon 
after  birth.  If  there  is  no  discharge 
of  meconium,  it  may  at  first  be  at- 
tributed to  constipation,  but  the  speedy 
development  of  vomiting  and  colic  set 
one  aright. 

As  regards  treatment,  the  simple 
stenosis  of  the  anus  may  only  require 
dilatation  with  the  oiled  finger  or  a 
bougie.  In  some,  however,  dissection 
of  the  occlusion  is  more  satisfactory. 
In  the  cases  of  imperforate  rectum,  if 
the  blind  end  is  not  too  far  from  the 

^  Bodenhamer,  W.:    "Malformation  of  the  Rectum  and  Anus,"  New  York,  1860. 


Fig.  684.— Represents  the  Perineum  and  Genitals, 
showing  Line  or  Division  of  Perineum  for 
Congenital  Rectal  Atresia  (after  Cruveilhier). 
o,  The  artificial  opening  made  at  the  normal  situation 

of  the  anus;    b,  the  rugous  and  prominent  raph^,  which 

became  linear  as  soon  as  meconium  was  voided;    c,  the 

abnormal  aperture,  or  anus. 


472 


INTESTINAL   SURGERY. 


surface,  it  may  be  brought  down,  and  stitched  in  place,  with  or  without  removal 
of  the  coccyx.  If  too  far  away  for  this  procedure  lumbar  or  inguinal  colostomy  is 
called  for.  In  these  severe  cases  there  is  not  much  time  for  delay,  and  the  danger 
from  stercoremia  renders  speedy  relief  necessary. 

In  some  cases  the  after-treatment  is  complicated  by  marked  constipation,  due 
either  to  the  undeveloped  musculature  of  the  bowel  or  to  scanty  intestinal  fluids. 

This  is  relieved,  as  a  rule,  by 
appropriate  remedies,  as  castor 
oil  or  other  simple  laxatives. 


TUMORS  OF  THE  RECTUM. 

A  classification  of  tumors 
into  benign  and  malignant 
answers  all  practical  purposes, 
but,  as  is  well  known,  it  is 
frequently  impossible  to  differ- 
entiate a  benign  growth  from 
a  malignant  one  by  the  ap- 
pearance. Those  which  are 
apparently  perfectly  benign 
microscopically,  have  the  clini- 
cal characteristics  of  malig- 
nancy. Adenomata  which 
microscopically  appear  benign, 
clinically  prove  to  be  very 
malignant.  In  tumors  of  the 
glandular  type  Rokitansky's^ 
law  holds  good — i.  e.,  glands 
out  of  place  are  a  sign  of 
malignancy.  If,  for  example, 
we  find  that  the  glands  of  the 
mucosa  are  displaced  deep 
into  the  muscularis,  we  should  consider  the  condition  malignant,  even  though  it 
appear  benign  clinically. 

BenTgn  Tumors. 
Adenoma  (Figs.  686,  687). — This  variety  is  common  in  the  rectum  and  is  most 
frequent  in  young  subjects.  Children  who  have  enlarged  tonsils  and  nasal  polypi 
not  infrequently  have  rectal  adenomata.  These  tumors  may  be  single,  but  are 
generally  multiple.  They  are  very  prone  to  undergo  malignant  degeneration, 
especially  in  early  adult  life.  So  common  is  this  that  the  condition  polyposis 
intestini  is  a  common  forerunner  of  malignancy  in  all  portions  of  the  intestinal 
»  Rokitansky,  C:  Lehrb.  Path.  Anat.,  1861,  Bd.  iii. 


Fig.  685. — Absence  of  Anus  and  Rectum  (Bodenhamer). 
a.  The  liver  above  the  commencement  of  the  ascending  colon; 
b,  the  ascending  colon  which  here  takes  the  place  of  the  cecum,  and 
is  divided  into  two  branches,  from  one  of  which  springs  the  ap- 
pendix; c,  the  descending  colon  hanging  loosely  in  the  abdominal 
cavity;  d,  the  blind  end  of  the  colon;  e,  e,  e,  e,  the  parietes  of  the 
abdomen. 


BENIGN   TUMORS    OF   THE    RECTUM. 


473 


tract.  The  most  painstaking  ablation  of  these  tumors  should  be  accomplished 
immediately  after  their  recognition.  The  avoidance  of  malignancy  can  be  pre- 
vented only  by  early  and  thorough  excision. 

The  peritoneum  may  be  opened  accidentally  during  the  operation ;  in  this  event 
it  should  be  carefully  sutured  from  the  interior  of  the  rectum.  If  the  opening  is  very 
large,  a  suprapubic  section  should  be  resorted  to  and  the  aperture  closed  by  a  Lem- 
bert  suture.  A  rubber  tube  must  always  be  left  in  the  rectum  to  prevent  distention 
from  gas. 

Papilloma  is  frequently  met  with  in  the  lower  part  of  the  rectum,  or,  to  be  more 
exact,  at  the  mucocutaneous  junction.  They  are  sessile  growths,  have  a  tendency 
to  increase  in  size,  and  if  they  extend  to  the  rectum  may  cause  obstruction  and  venous 
stasis.     As  is  the  case  with  the 

adenomata,  they  are  subject  to  °-  x^=--=^,-^ — 

malignant  degeneration.  ^„^~ 

These  growths  can  be  re- 
moved by  a  careful  submucous 
dissection   or  by  the   Paquelin 


Fig. 


'. — Peduncui^ated  Adenoma  OF  Large         Fig.  687. — Adenoma  of  Intestine  with  Depression  at  its 
Intestine  (Watt's  case).  Base. 

a,  Adenoma  ;    b,  depression. 


cautery,  as  they  never  penetrate  the  wall.  If  they  are  excised,  the  raw  surface 
should  be  cauterized.  For  all  cauterizations  the  writer  has  adopted  the  artist's  open- 
tipped  pyrography  burner.  This  has  the  advantage  of  incinerating  the  tissues 
with  the  hot  gas,  without  contact,  as  in  the  other  cauteries,  whereby  the  eschar  is 
often  pulled  off  with  the  instrument.  It  is  easily  kept  in  order,  a  decided  ad- 
vantage over  the  Paquelin. 

Fibroma. — These  originate  from  the  submucous  tissue  and  vary  in  size.  The 
largest  on  record  was  one  extirpated  by  Bowlby,  which  weighed  800  grams. 

Lipoma  is  rarely  met  with  and  originates  from  the  fat  in  the  vicinity  of  the  rectum. 

Dermoids  may  originate  in  the  retrorectal  tissues.  (Their  description  and  treat- 
ment are  referred  to  elsewhere.) 

Cysts. — Retention  cysts  are  met  with,  due  to  damming  up  of  the  secretions  of  the 
glands  about  the  anus  and  the  surrounding  skin. 

Myoma,  fibromyoma,  chondroma,  and  osteoma  are  all  found  in  this  region  oc- 
casionally, but  need  no  special  mention. 


474  INTESTINAL    SUEGERY. 

General  Treatment  of  Non-malignant  Tumors. — The  main  questions  to  be 
considered  are,  Does  the  tumor  involve  the  mucosa  alone?  and,  Is  the  growth 
situated  below  or  above  the  level  of  the  peritoneal  folds  ?  Tumors  involving  only 
the  mucosa  can  be  dissected  away  from  the  submucous  tissue  easily  and  safely. 
Adenomata,  as  we  have  stated,  have  a  tendency  to  involve  the  submucous  and 
muscular  coats;  therefore,  while  they  have  the  aspect  of  benign  tumors,  they  should 
be  treated  as  malignant  growths — by  radical  extirpation  including  the  rectal  wall. 
When  the  tumor  is  situated  high  up,  excision  must  be  very  carefully  performed  lest  the 
cul-de-sac  of  the  peritoneum  be  opened.  If  this  is  not  recognized  at  once,  life  is 
generally  sacrificed.  If  the  pedicle  is  small,  simple  ligation  followed  by  amputation 
is  the  safest  method;  the  ligature  causes  pressure  necrosis  and  agglutination,  avoid- 
ing danger  of  peritonitis. 

The  pedicle  should  never  be  transfixed.  If  the  ligature  penetrates  the  peritoneum, 
it  opens  a  direct  track  for  infection;  if  it  penetrates  a  vein,  it  leads  to  hemorrhage 
and  pylephlebitis.  The  writer  has  observed  all  these  pathologic  conditions.  "When 
the  tumor  is  sessile,  an  intestinal  clamp  should  be  placed  on  the  base,  and  the  tumor 
amputated;  the  pedicle  should  be  cauterized  to  secure  hemostasis  and  prevent  in- 
fection. 

Malignant  Tumors  of  the  Rectum. 
Carcinoma. — Varieties : 

1.  Squamous-celled  or  epithelioma,  always  found  at  the  muco-cutaneous 
junction. 

2.  Glandular  or  adenocarcinoma.  This  is  subdivided  into  (a)  medullary,  and 
(6)  scirrhus,  according  to  the  greater  or  lesser  abundance  of  epithelial  compared  to 
the  connective-tissue  elements. 

3.  Melanotic  pigmented  adenocarcinoma,  indicating  a  superlative  degree  of 
malignancy. 

We  learn  from  Gant^  that  5.9  per  cent,  of  all  carcinomata  originate  in  the 
rectum,  and  that  it  is  the  site  of  80  per  cent,  of  all  intestinal  cancers.  In  his 
own  practice  52  per  cent,  of  rectal  carcinomata  occurred  in  males  and  48  per  cent,  in 
females. 

The  etiology  of  carcinoma  in  the  rectum  is  the  same  as  elsewhere  in  the  body, 
apparently  the  sequence  of  mild,  frequently  repeated  irritations  and  pressure. 

There  may  be  no  symptoms  for  a  considerable  length  of  time,  though  after  the 
tumor  reaches  a  certain  size  symptoms^ of  pressure  and  pain  are  noticed.  There  is 
tenesmus,  and  constipation  alternating  with  diarrhea.  The  most  characteristic 
sign,  however,  is  a  mucous  discharge  independent  of  bowel  movements,  which  is 
usually  the  first  one  to  attract  the  patient's  attention.  The  mucus  may  be  streaked 
or  mixed  with  blood.  With  the  lapse  of  time,  the  growth  ulcerates,  saprophytic 
decomposition  ensues,  gi^^ng  the  foul  odor  so  characteristic  of  carcinoma.  In  the 
scirrhus  variety  there  is  a  tendency  to  stenosis.     From  now  on  the  patient  exhibits 

'  Gant,  S.  G.:    "Diseases  of  Rectum  and  Anus,"  Phila.,  1902. 


MALIGNANT   TUMORS    OF   THE   RECTUM.  475 

the  same  train  of  symptoms  as  in  carcinoma  elsewhere.  Rectal  examinations  are 
entirely  too  infrequent,  considering  the  common  occurrence  of  rectal  irritation  and 
its  sequential  carcinoma. 

Sarcoma. — In  strong  contrast  to  carcinoma,  sarcoma  of  the  rectum  is  rare. 
Moreover,  while  sarcoma  in  other  parts  of  the  body  is  found  in  young  subjects,  as 
a  rule,  in  the  rectum  it  occurs  well  along  in  adult  life.  It  never  tends  to  stenosis, 
rarely  ulcerates,  but  occasionally  gives  rise  to  hemorrhage.  The  lumen  of  the  in- 
testine is  increased,  the  wall  is  indurated  but  smooth. 

Metastases  in  Carcinoma  and  Sarcoma. — In  the  first  stages  of  carcinoma  the 
disease  is  purely  local.  At  this  time  there  are  no  metastases,  which  is  a  forceful 
argument  for  early  removal.  Later  we  may  expect  metastases  in  50  per  cent,  of 
the  cases  (Gant).  Carcinomata  in  the  zones  richly  supplied  with  lymphatics  are 
prone  to  early  metastases;  for  example,  the  rectovesical  fold,  the  sphincteric  zone, 
and  the  muco-cutaneous  junction.  No  one  has  yet  determined  how  soon  after  the 
primary  invasion  of  the  basement  membrane  by  the  erratic  epithelial  cells  metastatic 
displacement  of  these  cells  takes  place.  It  is  a  clinical  fact  that  the  greater  the  pro- 
portion of  connective  tissue  and  the  more  scirrhus  the  growth,  the  later  the  meta- 
stases. Experiments  have  shown  that  the  degree  of  toxicity  of  a  cancer  is  in  direct 
ratio  to  the  percentage  of  epithelial  elements  in  the  growth.  The  scirrhus  is  the 
least,  the  encephaloid  the  most  toxic. 

General  Treatment  of  Malignant  Tumors. — This  may  be  divided  into  paUia- 
tive  and  radical.  It  is  not  necessary  to  devote  much  time  to  a  consideration  of 
the  palliative  treatment,  as  it  is  an  uncalled-for  and  dangerous  waste  of  time,  save 
in  inoperable  cases.  The  ir-ray  is  not  considered  an  exception  to  this  rule.  In  the 
inoperable  cases  the  use  of  zinc  chlorid  or  the  cautery  greatly  relieves  the  sense  of 
pressure  and  diminishes  the  discharge,  thus  lessening  the  discomforts  from  the 
disease. 

Technic  of  Zinc  Cauterizations  in  Inoperable  Cases. — After  the  artificial  anus 
has  been  established,  the  carcinomatous  zone  cureted,  and  hemostasis  secured,  an 
upper  packing  of  dry  gauze  is  inserted  to  protect  the  healthy  mucosa.  The  ulcerated 
and  excavated  zone  is  then  packed  with  gauze  saturated  in  a  30  per  cent,  solution  of 
zinc  chlorid.  A  lower  packing  of  sterile  gauze  is  now  introduced  and  allowed  to 
remain  for  thirty-six  hours  after  the  cauterization.  Frequent  lavage  with  boric  acid 
or  lysol  will  hasten  cicatrization. 

Radical  Treatment. — The  rectum  was  first  extirpated  by  Pajot  in  1739,  later 
by  Morgagni^  and  Lisfranc.^  It  may  be  removed  through  the  perineal,  sacral,  ab- 
dominal, or  abdomino-perineal  routes.  The  following  varieties  of  operations  are. 
applicable  to  the  varying  pathologic  conditions : 

1.  Bloodless  dilatation  of  the  sphincter.     (Simon.) 

2.  Circular  incision  around  the  anus.     (Lisfranc.) 

'  Morgagni,  J.  B. :   "Seats  and  Causes  of  Diseases,"  London,  1769,  L,  50. 

^Lisfranc,  J.:  "Memoire  sur  I'excision  de  la  partie  inferieure  du  rectum  devenue  carcino- 
mateuse,"  Paris,  1830. 


476 


INTESTINAL   SURGERY. 


3.  Perineal  methods : 

(a)  Posterior  division  of  sphincter.     (Dieffenbach.) 

(b)  Posterior  longitudinal  incision  with  retention  of  the  anus  and  sphincter. 

(Kocher.) 

(c)  Resection  of  coccyx.     (Kocher.) 


Fig.  688.-^;;<JuE>fD's  Method. 
Shows  first  step  of  freeing  of  anus  and  rectum. 

4.  Transsacral  method  with  resection  of  portions  of  sacrum: 
(a)  One-sitting.     (Kraske;    in  America,  Fenger.) 
(6)  Transverse  section.     (Bardenheuer;  Rose.) 

(c)  Oblique  section.     (Hochenegg,) 

(d)  Transverse  resection  of  sacrum  and  coccyx.     (Heineke;    Schlange: 

Kocher;  Hegar;  Rydygier;  Marcy.) 


MALIGNANT   TUMORS    OF   THE    RECTUM. 


477 


5.  Parasacral  methods,  division  of  soft  parts  on  side  of  sacrum  without  section 
or  excision  of  sacrum  or  coccyx.     (Zuckerkandl ;  Wolfler;   Schelkly.) 

6.  Vaginal  extirpation.     (Des  Quins;  Norton;  L.  L.  Mac  Arthur;  Campenom; 
Rehn;  Vautrin;  Price;   Byford;  Bristow;  JuKus  Sternberg.) 

7.  Primary  vaginal  celiotomy,  examination  of  extent  of  disease  and  then  com- 


^B^iLboca  vemosus 


-jniddle  hemorrhoidal 

Vessels 


Fig.  689. — Quenu's  Method. 
Showing  method  of  freeing  middle  portion  of  rectum. 

plete  division  and  later  excision  with  end-to-end  union  of  intestine — retention  of 
sphincter.     (Rehn;  Murphy.) 

Brief  descriptions  of  a  few  methods : 

Quenu's^  Perineal  Method. — Place  the  patient  in  the  lithotomy  position  and 
cauterize  the  anal  mucosa.  If  the  sphincter  is  to  be  preserved,  dissect  the  mucosa 
free  or  divide  the  rectum  circularly  above  the  muco-cutaneous  junction  and  sphincter 
^  Quenu  et  Hartmann:    "Chirurgie  du  Rectum,"  Paris,  1895-99. 


478 


INTESTINAL   SURGERY. 


border.  Then  split  the  sphincter  in  the  median  hne  in  front  and  behind,  displacing 
each  segment  laterally.  Deepen  the  incision  by  dividing  muscular  fibers  down  to 
the  coccyx  and  sacrum.  The  rectum  is  then  liberated  on  its  anterior  wall  up  to  the 
cul-de-sac  (Fig.  689).  To  gain  more  room  posteriorly  remove  the  coccyx  and  free 
the  rectum  from  its  attachments  as  high  up  as  the  promontory  of  the  sacrum.  After 
liberating  it  for  about  5  inches,  the  cul-de-sac  is  opened  (Fig.  690),  the  tissues  on 
either  side  of  the  bowel  are  clamped  close  to  the  latter,  and  then  divided  between  the 


Fig.  690. — QuiiNu's  Method. 
Showing  division  of  sigmoid  and  suture  of  same  to  skin. 


clamps  and  the  bowel.  The  sigmoid  is  then  liberated  and  drawn  down  to  permit 
its  attachment  without  tension  to  the  cutaneous  margin  (Fig.  690).  The  rectum 
is  excised  and  the  sigmoid  accurately  sutured  to  the  cutaneous  margin  or  sphincteric 
stump  of  the  rectum.  Post-procteal  drainage  should  be  instituted.  Quenu  re- 
ports a  series  of  thirteen  cases,  with  two  deaths,  one  from  sepsis  and  the  other  from 
gangrene  of  the  gut. 

Much  time  can  be  saved,  and  greater  accuracy  of  technic  exercised,  if  after  mak- 


MALIGNANT    TUMORS    OF   THE    RECTUM. 


479 


ing  the  supra-sphincteric  circular  division  the  anterior  and  posterior  walls  of  the 
rectum  are  split  with  the  scissors  up  to  the  cul-de-sac  and  promontory,  without  any 
previous  freeing  of  the  walls.  The  lateral  halves  can  then  be  readily  freed  from  the 
neighboring  structures  by  a  spreading  dissection  with  the  scissors.  The  operation 
may  then  be  completed  as  above. 

Sacral  Proctectomy.— In  1880  Bardenheuer  suggested  that  a  portion  of  the 
sacrum  be  removed  in  order  to  gain  more  room,  and  allow  removal  of  the  rectum 
higher  up.  The  credit  of  perfecting  this  to  a  practical  operation  belongs  to  Kraske 
(Figs.  691,  693),  who  in  the  same  year  described  the  procedure  in  detail  as  follows: 


Fig.  691.— Kraske's  Operation.     Coccyx  and  Part  of  Sacrum  Excised;  Rectum  Exposed. 


The  patient  is  placed  on  the  right  side;  a  median  incision  is  made  from  the  middle 
of  the  sacrum  to  the  tip  of  the  coccyx,  and  the  tissues  divided  down  to  the  bone 
from  the  third  sacral  vertebra.-  The  sacrum  is  divided  with  bone  forceps  trans- 
versely at  the  upper  angle  of  the  wound,  and  its  lower  half  with  the  coccyx  is  de- 
flected to  the  left;  the  rectum  is  freed  from  its  attachments  posteriorly.  The  patient 
is  then  changed  to  the  hthotomy  position;  the  anterior  attachments  of  the  rectum 
are  then  severed,  freeing  it  completely.  The  rectum  and  sigmoid  are  then  drawn 
down,  the  former  excised,  and  the  latter  united  to  the  sphincteric  stump  or  the  cu- 
taneous margin.     The  lower  end  of  the  bowel  may  be  sutured  to  the  post-sacral 


480 


INTESTINAL   SURGERY, 


wound;  in  both  cases  drainage  is  instituted.  (Kraske's  incision  has  been  modified 
by  Hochenegg/  Bardenheuer,  Levy/  Rydygier,'  Hegar/  Rose,  and  von  Heinecke^ 
(Figs.  692,  693).  Bardenheuer  removes  the  entire  sacrum  below  the  third  foramen. 
The  Rehn-Rydygier  method  (first  described  by  Rehn*'  in  1890,  and  by  Rydygier 
independently  later  on)  is  performed  as  follows:  A  vertical  incision  is  made  from 
the  posterior  superior  spinous  process  to  the  coccyx  one-half  inch  from  the  left  margin 
of  the  sacrum;  from  the  coccyx  it  is  continued  in  the  middle  hne  to  the  anus.     The 


Fig.  692. — Rehn-Rydygier  Method  of  Extirpation  of  the  Rectum. 
a,  Line  of  cutaneous  incision ;  b,  line  of  cutaneous  and  bony  incision. 


left  sacrosciatic  ligaments  are  severed  and  the  anterior  surface  of  the  sacrum  freed 
from  its  attachments.     A  transverse  section  is  made  below  the  third  sacral  foramen 

*  Hochenegg,  Julius:  " Behandlungsresultate  bei  Dickdarmcarcinom,"  Berlin,  klin.  Woch., 
1902,  xxxix,  343. 

'■  Levy,  Wm.:   "Zur  Technik  der  Mastdarmresektion,"  Cent.  f.  Chir.,  1889,  xvi,  218. 

^  Rydygier:  "Eine  neue  Methode  der  temporiiren  Resektion  des  kreuzsteifsbeines  behufs 
Freilegiing  der  Beckenorgane,"  Cent.  f.  Chir.,  1893,  xx,  1. 

^  Hegar  and  Kaltenbach:    "Die  Operative  Gynakologie,"  Stuttgart,  1897. 
5  Heinecke,  W.:    "Ein  Vorschlag  zur  Exstirpation  hochgelegener  Rectumcarcinome,"  Miinch. 
med.  Woch.,  1888,  xxxv,  1615. 

"  Liermann,  W.  (Rehn):  "Vaginale  Mastdarmoperationen,"  Beitrag  zur  klin.  Chir.,  1899, 
XXV,  89. 


MALIGNANT    TUMORS    OF   THE    RECTUM. 


481 


and  the  bone  divided  at  this  point.     The  osteo-tegumentary  flap  is  then  reflected,  the 
rectum  exposed,  and  after  the  tumor  is  removed  the  flap  is  replaced. 


Krd  she's. 


Hochenegg's. 


Bardenheuer's. 


Rose's. 


von  ffei'necke's. 


Levy's. 


Jfjrdygier's. 


He  gar's. 


Fig.  693.     Various  Lines  of  Division  of  Sacrum  for  Procte 


Vaginal  Extirpation  of  the  Rectum.— Exchion  of  the  rectum  by  either  the  peri- 
neal, parasacral,  or  transsacral  routes,  though  presenting  technical  diflSculties,  is 


VOL.   II — 31 


482 


INTESTINAL   SUKGERY. 


free  from  accidental  wounding  of  the  peritoneum.  The  mortaHty  by  these  procedures 
in  fourteen  of  the  larger  clinics  was  21.2  per  cent.  (Prutz^). 

Attempts  at  removal  of  the  pathologic  conditions  in  the  rectum  through  the 
vagina  were  made  as  far  back  as  1890.  We  find  the  operation  of  vaginal  proctectomy 
advancing  in  the  direction  of  the  peritoneum  and  sigmoid,  without  any  definite 
plan  as  to  vaginal  celiotomy  for  the  removal  of  carcinoma  of  the  first  part  of  the 
rectum  or  lower  part  of  the  sigmoid. 

The  following  is  the  technic  of  an  operation  first  performed  by  the  writer  in  1898,^ 
on  a  patient  with  a  malignant  tumor  of  the  first  and  second  portions  of  the  rectum. 


Fig.  694. — Vaginal  Proctectomy. 

Sagittal  section  showing  the  normal  relationship  between  vagina  and  rectum.     The  malignant  growth  is  shown 

occupying  the  first  and  second  portion  of  the  rectum.     The  lines  of  intended  excision  are  shown. 


With  the  patient  in  the  lithotomy  position,  the  vagina  was  dilated  with  broad  specula, 
the  cervix  drawn  down,  and  the  cul-ds-sac  opened  by  a  transverse  incision  similar 
to  that  used  in  vaginal  hysterectomy.  Large  laparotomy  sponges  were  inserted  into 
the  peritoneum  to  retain  the  intestines;  the  rectovaginal  septum  was  divided  down 
to  the  rectal  wall  in  the  median  line  from  the  cul-de-sac  to  the  sphincter  (Fig.  695). 
Hemorrhage  from  the  dilated  veins  was  readily  controlled.  The  posterior  vaginal 
wall  was  dissected  from  its  attachment  to  the  rectum ;  retractors  were  placed  laterally 

^  Prutz,  W.:    "Bemerkungen  zur  Statistik  der  sacralen  Exstirpation  des  Mastdarmkrebses, " 
Arch.  f.  klin.  Chir.,  1900,  Ixii,  398. 

^  Murphy,  J.  B.:  "Resection  of  the  Rectum  per  vaginam,"  Phila.  Med.  Jour.,  1901,  vii,  383. 


MALIGNANT    TUMORS    OF   THE    RECTUM. 


483 


and  anteriorly  so  as  to  secure  a  large  field  for  operation  (Fig.  696).  The  sigmoid 
was  handled  throughout  its  entire  extent  and  brought  down  without  difficulty.  (I 
wish  here  to  emphasize  this  mobility  of  the  sigmoid  by  referring  to  a  case  in  which 
an  operator  perforated  the  posterior  wall  of  the  uterus  with  the  curet,  and  drew  down 
through  the  opening  17  inches  of  the  sigmoid  and  colon.)  The  anterior  rectal  wall 
to  the  sphincter  is  divided  with  scissors  as  far  as  the  lower  border  of  the  tumor. 
The  anal  segment  is  separated  from  the  tumor  by  incision  from  1  to  I2-  inches  below 


Fig.  695. — Vaginal  Proctectomy. 
o,  Denudation  of  vaginal  mucosa  on  the  posterior 
fornix  with  divided   peritoneum  ;     b,  vertical   incision 
in  the  rectovaginal  septum. 


Fig.  696. — Vagixal  Proctectomy. 
a.  Dissection  of  rectovaginal  flaps  separating  them 
from   their   rectal   attachments  ;     b,  retractors  placed 
in  position. 


the  growth;  this  incision  must  extend  into  the  post-rectal  connective  tissue  (Fig.  697). 
The  proximal  end  of  the  rectum  is  grasped  with  short  gastrectomy  forceps,  thus  clos- 
ing it  completely.  Then  with  curved  scissors  an  extensive  dissection  is  made, 
liberating  the  rectum  from  the  coccygeal  and  post-rectal  attachments,  upward  to  the 
promontory  of  the  sacrum,  and  even  over  the  iliac  vessels  (Fig.  698).  During  this 
stage  of  the  operation  the  hemorrhage  is  very  profuse,  but  can  be  easily  controlled  by 
forceps  and  pressure.     The  sigmoid  is  loosened  sufficiently  to  allow  the  healthy  por- 


484 


INTESTINAL    SURGERY. 


tion  of  the  bowel  to  come  well  down.  The  rectum  is  double  clamped  and  amputated 
1 1  inches  above  the  upper  border  of  the  tumor  growth.  The  sigmoid  and  sphincteric 
segment  of  the  rectum  are  united  end-to-end  with  silk.  The  sutures  are  passed  from 
within  outward,  so  all  the  knots  are  on  the  inside  of  the  bowel;  the  ends  of  the  sutures 
are  left  long  and  drawn  down  through  the  anus  to  facilitate  removal.  The  incision 
in  the  anterior  wall  of  the  rectum  is  closed  with  silk,  also  introduced  in  the  manner 
just  described.     The  sphincter,  if  divided,  is  then  united  by  buried  sutures  of  catgut 


Fig.  697. — Vaginal  Proctectomy. 
T-shaped  incision  on  the  anterior  wall  of   the  rectum. 


Fig.  698. — Vaginai.  Proctectomy. 

a.  Segment  of  rectum  with  growth  excised  ;  b,  proximal 

end  of  healthy  rectum  ;    c,  stump  of  distal  end. 


(Fig.  699).  The  laparotomy  sponges  having  been  removed,  the  peritoneal  cavity 
is  shut  off  by  closing  the  peritoneum  with  a  continuous  catgut  suture.  The  vaginal 
wall  is  sutured  to  the  cervix  by  closing  the  transverse  incision,  and  the  edges  of  the 
vertical  incision  are  united  in  the  central  raphe  with  deep  silkworm-gut  sutures  in- 
cluding the  perineal  muscles  (Fig.  700).  A  large  rubber  drainage-tube,  an  inch  in 
diameter,  is  introduced  into  the  rectum  and  sewed  in  place. 
The  advantages  offered  by  the  vaginal  route  are: 
1.  The  sacrum  and  posterior  bony  wall  of  the  pelvis  are  not  disturbed. 


MALIGNANT    TUMORS    OF   THE   RECTUM. 


485 


2.  The  field  of  operation  is  as  extensive  and  the  anatomic  parts  as  accessible  as 
in  the  transsacral  operations. 

3.  The  peritoneal  cavity  is  opened  in  both  the  vaginal  and  sacral  operations,  and 
in  neither  is  it  a  source  of  great  danger. 

4.  The  diseased  tissue  is  more  accessible  for  inspection  and  the  extent  to  which 
the  operation  may  be  carried  in  an  upward  direction  is  as  great,  if  not  greater,  than 
by  the  sacral  route. 

5.  The  peritoneum  may  be  drained  freely  through  ,the  vagina. 


I'iG.  699. — Vaginal  Proctectomy. 


Silk   sutures    closing   opening   on  anterior  rectal  wall, 
all  knots  tied  within  the  rectum. 


Fig.  700. — Vaginal  Proctectomy. 
Vaginal  wall  sutured  to  cervix,  closing  transverse 
incision;    vertical    incision    closed    with    kangaroo    or 
chromoform  sutures. 


6.  A  perfect  end-to-end  approximation,  either  by  suture  or  by  the  use  of  the 
button,  may  be  secured.  The  preferable  method  of  uniting  the  two  ends  is  by  in- 
terrupted sutures  of  silk,  because  as  there  is  no  peritoneum  on  the  sphincteric  seg- 
ment, failure  of  union  with  the  button  is  to  be  feared. 

7.  The  sphincter  is  retained  and  the  perineal  body  is  restored.  There  is  di- 
minished action  of  the  levator  ani  muscle. 

8.  When  the  operation  is  complete,  the  parts  are  practically  in  their  normal 
positions. 


486  INTESTINAL   SURGERY. 

I  have  performed  the  same  operation  on  the  male  cadaver,  and  find  that  by 
spHtting  the  sphincter  directly  through  the  median  line,  anteriorly  and  posteriorly, 
cutting  back  to  the  coccyx  and  opening  the  rectovesical  fold  of  the  peritoneum, 
practically  the  same  field  for  operation  can  be  obtained  as  in  the  female.  Several 
inches  of  the  bowel  can  be  excised  and  end-to-end  union  secured.  Either  ante- 
procteal  or  post-procteal  drainage  may  be  used.  The  cut  ends  of  the  sphincter  are 
united  anteriorly  and  posteriorly.  The  lateral  nerve-supply  on  either  side  is  not 
disturbed. 

Ahdomino-ferineal  Oferation. — The  following  is  a  description  of  this  operation 
by  C.  H.  Mayo:^ 

"The  patient  is  placed  in  the  high  Trendelenburg  position  and  the  abdomen 
freely  opened  in  the  middle  line.  The  upper  limits  of  the  growth  and  its  relation 
to  the  surrounding  tissues  are  noted.  The  possibility  of  the  removal  of  all 
of  the  obviously  infected  glands  is  ascertained,  and  the  liver  examined  for  embolic 
carcinoma.  If  the  case  is  a  favorable  one,  the  intestines,  with  the  exception  of  the 
sigmoid,  are  carefully  packed  away  with  large  gauze  pads;  two  clamps  are  caught 
across  the  lower  sigmoid  on  a  level  with  the  promontory  of  the  sacrum  and  the 
bowel  divided  between.  The  mesosigmoid  is  liberated  by  lateral  incisions  and  the 
proximal  fragment  brought  up  outside  of  the  abdominal  wound.  A  ligature  is 
thrown  around  the  bowel  immediately  below  the  forceps,  which  are  removed  as  the 
ligature  is  drawn  tight.  A  purse-string  suture  is  placed  an  inch  below  the  end  of 
the  stump,  which  is  invaginated  in  a  manner  similar  to  that  of  the  appendix.  The 
ends  of  the  ligature  are  left  long.  The  threads  and  stump  are  carefully  cleansed. 
The  distal  stump  is  treated  by  inversion  in  a  similar  manner,  to  prevent  soiling. 
Lateral  and  anterior  peritoneal  incisions  are  now  made,  liberating  the  rectum  from 
the  bladder  and  prostate  in  the  male  and  from  the  uterus  in  the  female.  The 
inferior  mesenteric  artery,  which  is  the  upper  continuation  of  the  superior  rectal,  is 
caught  and  tied  above  and  to  the  left  of  the  promontory  of  the  sacrum  at  as  high  a 
point  as  can  be  safely  done  without  interfering  with  the  nutrition  of  the  bowel  used 
in  the  colostomy.  The  fat  is  carefully  separated;  the  entire  mass  of  gland-bearing 
fascia,  with  the  fat,  is  wiped  perfectly  clean  to  the  periosteum.  The  middle  sacral 
artery  is  of  considerable  size  in  most  cases,  and  should  be  caught  and  ligated  near 
its  origin  from  the  abdominal  aorta  between  the  common  iliac  vessels.  The  dis- 
section is  continued  downward,  exposing  the  internal  iliac  vessels  and  the  ureters. 
Most  of  this  can  be  done  by  sponging.  The  middle  hemorrhoidal  vessels  are  caught 
laterally,  as  they  come  ofT  with  the  inferior.  The  entire  area  is  now  packed  with 
hot  moist  gauze,  and  the  patient  put  in  the  perineal  position.  In  some  cases,  if 
the  bowel  is  healthy  for  a  space  of  four  inches  above  the  anus,  it  is  clamped  and 
ligated  at  this  point,  and  cut  above  the  ligatures,  the  diseased  area  being  removed. 
The  operator,  or  preferably  a  second  operator,  begins  the  lower  part.  A  pair  of  for- 
ceps are  passed  into  the  blind  pocket  of  bowel  from  below,  the  tied  end  of  the  bowel 

'  Mayo,  C.  H.:  "Cancer  of  the  Sigmoid  and  Rectum,"  Surgery,  Gynecology,  and  Obstetrics, 
1906,  iii,  236. 


MALIGNANT   TUMORS    OF   THE   RECTUM.  487 

is  pushed  into  the  open  forceps,  and  they  are  withdrawn  through  the  anus,  inverting 
the  bowel. 

"After  cleansing,  the  thread  of  closure  is  cut  and  the  forceps  are  now  passed 
through  the  invaginated  bowel  and  anus  into  the  pelvis  to  grasp  the  proximal  end  of 
bowel,  which  is  withdrawn,  and  the  two  ends  united  by  a  circular  end-to-end  closure 
outside  the  anus  and  allowed  to  retract.  Drainage  is  secured  by  a  midline  incision 
in  front  of  the  coccyx,  through  which  tube  drainage  into  the  pelvis  is  made.  In 
some  colostomies  the  lower  end  of  the  rectum  can  be  saved  as  a  blind  pouch,  or 
temporarily  employed  for  drainage  of  the  pelvis.  Should  the  disease  require  such 
extensive  removal  of  the  rectum  as  to  destroy  the  lower  rectal  wall  muscles  and  nerves, 
as  well  as  straighten  the  sigmoid  loop,  thereby  losing  both  retention  and  control,  it  is 
preferable  to  save  the  sigmoid  loop  as  such  and  make  an  abdominal  anus.  To 
employ  this  method,  a  small  gridiron  incision  is  made  on  the  left  side,  as  would 
be  done  on  the  opposite  side  for  appendicitis,  and  through  this  opening,  using  the 
ends  of  the  threads  as  a  tractor,  the  proximal  stump  is  pulled  out  three-fourths  of  an 
inch  beyond  the  skin  surface.  Three  or  four  linen  sutures  are  quickly  placed,  uniting 
the  bowel  to  the  peritoneum  on  the  inner  side,  and  a  silkworm-gut  suture  on  the  out- 
side closes  each  angle  of  the  wound,  including  in  its  bite  the  skin,  aponeurosis  of  the 
external  oblique,  and  the  wall  of  the  bowel,  holding  it  securely  in  position.  If  this 
plan  is  followed,  the  operator  from  below,  after  inserting  the  gauze  in  the  rectum 
to  facilitate  subsequent  dissection,  and  closing  the  anus  by  a  circular  suture,  circum- 
scribes the  anal  margin  with  a  deep  incision,  and  dissects  the  perineal  portion  of  the 
rectum  with  its  muscles  and  fat  free  from  the  prostate  and  urethra,  or  from  the 
vagina  in  women.  This  extends  up  to  the  levator  ani  muscle,  which  forms  the 
boundary  between  the  upper  and  lower  dissections.  The  abdominal  operator 
now  passes  down  the  fragment  of  lower  sigmoid  and  the  upper  end  of  the  rectum 
with  its  fat  and  glands  into  the  perineal  opening,  where  they  are  removed  by  the 
surgeon  working  below,  or  one  operator,  with  changes  of  gloves,  can  accomplish 
the  work  in  both  fields.  All  bleeding-points  are  caught  and  ligated.  A  considerable 
sized  gauze  drain  is  passed  from  above  downward,  leaving  its  upper  end  exposed 
just  on  a  level  with  the  peritoneum,  which  is  drawn  together  to  cover  as  much  as 
possible,  the  external  gauze  portion  being  brought  out  of  the  perineal  wound.  The 
sigmoid  loop  from  above  is  placed  over  the  exposed  surface,  and  in  the  female  the 
body  of  the  uterus  and  broad  ligaments  are  adjusted  with  a  few  sutures  to  aid  in 
covering.  The  upper  incision  is  completely  closed,  while  the  perineal  opening  is 
narrowed  to  proper  dimensions  for  drainage  by  a  few  sutures. 

"The  end  of  the  sigmoid  is  left  completely  obstructed  for  the  first  twenty-four 
hours,  after  which  time  the  circular  suture  is  cut  and  the  stump  everted  by  the  liga- 
ture, which  is  tied  around  it,  and  the  bowel  opened. 

"The  advantages  of  the  operation  herein  outlined  are  obvious.  The  disease 
is  removed  widely,  with  all  of  its  tributary  lymphatics,  muscles,  and  related  tissues. 
The  anus  is  placed  in  a  position  easy  of  inspection  and  cleansing;  the  sigmoid  trap 
obviates  the  necessity  of  frequent  stools,  and  the  intermuscular  incision  gives  a  fair 
degree  of  control." 


488  INTESTINAL    SURGERY. 

The  following  statistics  are  of  great  practical  interest  in  the  rectal  cancer  problem : 

STATISTICS  OF  OPERABILITY  OF  RECTAL  CANCER.— (Gani.) 

Percentage. 

Czerny  (Heidelberg) 71.1 

Zurich  clinic 50.0 

Zurich  clinic 55.8 

Gottingen 78.3 

Marburg 75.4 

Breslau 16.6 

Freiburg  (Ivraske) 73.0 

Rostock 47.2 

Von  Bergmann's  Clinic 80.0 

Bonn  (Schede)  (Added  by  the  writer) 78.7 

VOGEL'S  MODIFICATION   OF   KRONLEIN'S   TABLE   ON   THE   OPERABILITY  AND 
MORTALITY  OF  KRASKE'S  OPERATION.— (Gan^.) 

No.  OF  Cases  Percentage  Percentage  Oper- 

Operator.  Treated.  Operated,      ative  Mortality. 

Konig 120  78.3  32.5 

Czerny 151  71.1  10.0 

Kronlein.  .  .  .  ; 110  57.2  11.1 

Gussenbauer 259  56.0  22.7 

Von  Bergmann 155  80.0  32.0 

Madelung,  Garre 115  46.0  19.0 

Kraske 110  78.0  11.7 

Kuster 126  75.4  25.2 

Hochenegg 141  66.0  8.6 

Mikulicz 109  60.6  25.7 

Helferich 46  48.0  13.6 

Schede 66  80.3  32.0 

PERMANENT    RESULTS    OBTAINED    FROM    RECTAL    EXCISION     BY    LEADING 
OPERATORS  OF  EUROPE.— (Gan^.) 

Percentage  Per- 
Operator.  manent  Cures. 

Kocher 28.5 

Von  Bergmann 17.4 

Kuster 16.8 

Kronlein 16.0 

Czerny 14.6 

Kraske 13.7 

Hochenegg 12.9 

Madelung 11.3 

Mikulicz ; 9.7 


STRICTURE  OF  THE  RECTUM. 

A  narrowing  of  the  bowel  due  to  previous  inflammation  or  ulceration,  and 
characterized  by  pain  and  disturbances  of  defecation. 

There  are  many  varieties;  the  most  simple  and  practical  classification,  however, 
is  into  (a)  malignant  and  (h)  non-malignant. 

The  condition  is  more  common  in  women  and  is  very  frequent  in  negroes.  A 
very  practical  classification,  from  an  etiologic  standpoint  is  into:  (1)  Congenital; 
(2)  traumatic;  (3)  venereal;  (4)  spasmodic;  (5)  catarrhal;  (6)  tuberculous;  (7) 
varicose;  (8)  pressure  of  diseased  organs  and  tumors  on  the  rectum;  (9)  valvular  and 
band-like  (Gant). 

Congenital  strictures  and  atresia  ani  are  rare,  but  are  easily  recognized;  they 
may  be  associated  with  diarrhea  of  frequent,  small,  slimy  discharges.      They  are 


STRICTURE    OF   THE    RECTUM.  489 

usually  near  the  muco-cutaneous  margin,  though  occasionally  they  may  exist  as 
small  sinuses  considerably  higher.  The  bowel  above  the  constriction  may  be  greatly 
dilated  and  the  abdomen  tympanitic. 

Traumatic  Stricture. — Trauma  is  a  frequent  cause  as  a  sequence  of  protracted 
labor,  misapplied  pessaries,  forceps  deliveries,  etc. 

Venereal  stricture  is  the  most  common.  Syphilis  is  the  most  frequent  cause; 
gonorrhea  is  rarely  an  etiologic  factor.  Cooper  and  Edwards  claim  that  a  syphilitic 
history  can  be  obtained  in  every  case  of  benign  stricture. 

Some  idea  of  the  relative  significance  of  the  etiologic  factors  may  be  gained  from 
the  following  table  (Cripps^) : 

Syphilis 13 

Childbirth 8 

Operations  for  hemorrhoids. . ; 8 

Operations  for  fistula 2 

Congenital 2 

Inflammation  of  the  bowels 2 

Internal  fistula 2 

Dysentery 2 

Tuberculous  disease 1 

Unassigned 30 

Total  (7  males,  63  females) 70 

Spasmodic  or  phantom  stricture  may  result  from  muscular  spasm.  As  Gant  ob- 
serves, "the  rectal  valves  have  been  frequently  confused  with  this  condition." 

Catarrhal  inflammation  of  long  standing  may  give  rise  to  ulceration.  Tliis  is 
followed  by  the  formation  of  cicatricial  tissue  which  infiltrates  the  wall  and  sub- 
sequently contracts  to  an  obstructive  degree. 

Tuberculous  stricture  is  excessively  rare,  not  because  of  the  infrequency  of  tuber- 
culosis in  this  region,  but  on  account  of  the  inability  of  tuberculous  ulcers  to  undergo 
repair  and  develop  sufficient  connective  tissue  for  contraction  (Fig.  701).  Caird 
reports  an  interesting  case  (Fig.  701).  The  treatment  is  by  excision  of  the  tuber- 
culous portion,  if  circumscribed,  the  same  as  for  malignant  disease.  The  period 
of  healing  is  extremely  slow  and  results  are  unsatisfactory. 

Varicose  strictures  are  not  common. 

Pressure  from  without,  such,  for  instance,  as  that  from  a  retroverted  uterus, 
fibromyoma,  intraligamentous  cysts,  pelvic  exudates,  or  post-procteal  dermoids, 
may  produce  occlusion  of  the  lumen,  without  a  mural  constriction. 

Valvular  and  band-like  constrictions  of  the  rectum  may  be  either  single  or  multiple 
and  occur  without  erosion  of  the  mucosa  and  without  evidence  of  previous  inflamma- 
tory condition  (Figs.  703,  704).  They  form  like  a  diaphragm  in  the  submucous 
connective  tissue,  tending  to  contract  to  almost  complete  occlusion.  The  same 
pathologic  condition  is  observed  higher  up  in  the  alimentary  tract.  After  segmental 
resections  of  the  bowel,  this  tendency  to  stenosis  is  common. 

Symptoms. — There  are  no  symptoms  in  the  beginning,  as  a  rule;  the  first 
manifestations  occur  when  the  stenosis  is  sufficient  to  produce  a  coprostasis,  as 
*  Cripps,  H.:  "  Dis.  Rectum  and  Anus." 


490 


INTESTINAL   SURGERY. 


shown  by  intractable  obstipation.  As  the  stenosis  becomes  more  marked,  diarrhea 
and  tenesmus  develop.  Pain  is  generally  of  a  bearing-down  character.  The 
diagnosis  may  be  made  by  digital  examination  or  by  the  proctoscope. 

Treatment. — Treatment  will  naturally  depend  on  the  etiologic  factors  and 
the  type  of  contraction. 


-a 


Fig.  701. — Stricture  of  Ileum  op  Tuberculous  Origin   (after  Caird). 
a.  Seat  of  stricture. 


Dilatation. — In  annular  or  short  tubular  strictures  of  post-inflammatory  origin 
the  condition  may  be  relieved  by  gradual  dilatation  with  bougies  of  hour-glass 
shape;  also,  massage  to  favor  absorption  of  the  cicatricial  tissue.  The  bougie 
should  remain  in  place  for  hours  at  a  time,  even  when  the  patient  is  walking  about. 
It  should  not  be  used  when  there  is  tuberculous  disease  of 
the  rectum.  If  this  palliative  treatment  fails,  operative 
measures  must  be  resorted  to. 

Bacon's  method  of  operating  consists  in  excluding  the 

stricture  from  the  fecal  circuit.     The  abdomen  is  opened 

and  the  sigmoid  is  folded  over  upon  the  rectum  below  the 

site  of  the  stricture.     A  side-to-side  approximation  is  then 

made  with  the  button  between  the  sigmoid  and  the  rectum 

below  the  stricture.     The  male  half  is  introduced  through 

the  sigmoid,  the  female  half  through  the  anus  by  a  special 

trocar,  which  serves  two  purposes:  (1)  to  perforate  the  wall 

of  the  rectum;  and  (2)  to  hold  the  button.      The  spur  between  the  two  segments 

of    bowel  is  subsequently  destroyed  by  a  clamp  on  the  Dupuytren  principle  (Figs. 

705,  706). 

For  strictures  located  just  above  the  internal  sphincter  this  author  ad\'ises  per- 


FiG.  702. — Proctoscopic 
View  in  a  Case  of  Stric- 
ture OF  the  Rectum. 


STRICTURE    OF   THE   RECTUM. 


491 


forating  the  mucosa  on  the  posterior  wall  by  an  aneurism  needle  threaded  with 
silk,  and  introduced 
from  within  the 
lumen.  The  needle 
is  then  carried  back- 
ward as  well  as  up- 
ward in  the  periproc- 
teal  tissue,  thus  en- 
circling the  stricture. 
The  free  ends  are 
tied  and  the  ligature 
left  in  place  about 
three  months.  The 
tissues  are  then  di- 
vided with  the  cau- 
tery. The  cauter- 
ized tissues  will 
not  unite,  thus  pre- 
venting the  recur- 
rence of  the  strict- 
ure. Bacon  cites 
several  cases  as  "apparently  cured,"  and  three  "partial  failures." 


Fig.  703. — Stricture  of  Rectum. 
a,  Cicatricial  band  in  rectal  wall;    b,  dilatation  above  the  sphincter. 


Hartmann^  advocates 
excision  of  the  segment  of 
the  rectum  and  suture  of  the 
remaining  segment  to  the 
skin. 

Sigmoidorectostomy  was 
first  described  by  Rotter,^ 
and  by  Ries^  later  on  and 
independently.  After  open- 
/  ing  the  abdomen  the  sig- 
moid is  hgated  in  two  places 
and  divided  between  by  the 
cautery;  the  distal  end  is 
closed  and  the  proximal  end 
protected  by  gauze.  After 
placing  the    patient   in  the 

Fig.  704. — Multiple  Strictures  of  Intestine   (a,  a).  Hthotomv   position,  the   rCC- 

^Hartmann:  Op.  cit. 

^  Rotter,  J.:    "Die  Sigmoideo-Rectostomie,  ein  neues  Verfahren  zur  Beiseitigung  von  Mast- 
darmstricturen,"  Archiv  f.  klin.  Chir.,  1899,  Iviii,  .334. 

=  Ries,  Emil:     "The  Treatment  of  Extensive  Rectal  Strictures,"  N.   Y.  Med.   Jour.,  1902, 
Ixxvi,  1028. 


492 


INTESTINAL    SURGERY. 


Strict  urei 


Murphy- 
button 


Fig.  705. — B .icon's  Method  for  Stricture  of  Rectum. 

to  vaginal  septum  is  incised  and  the  bowel  drawn  through;  the  abdominal  wound 
is  then  closed.  The  anterior  rectal  wall  is  now  opened  between  the  sphincter  and 
the  stricture,  and  the  bowel  sutured  in  the  opening  by  apposing  the  mucous  edges. 


Stricture 

Fig.  706.- — Bacon's  Method  for  Stricture  of  the  Rectdm. 
Dupuytren's  clamps  applied   to  septum. 


FISTULA    IX   ANO. 


493 


Sacral  colorectosfoviy  is  an  osteoplastic  procedure.  The  rectum  is  exposed  bv 
dividing  soft  tissues  and  bone.  Once  the  rectum  is  exposed  it  may  be  treated  in  the 
same  manner  as  Bacon's  method  of  proctotomy. 

In  all  operations  for  stricture  of  the  rectum  an  efficient  sphincter  should  be  re- 
tained. Furthermore,  when  exsection  is  practised  a  large  strip  of  rectum  must  be 
removed,  so  that  the  sigmoid  can  be  utilized  to  replace  the  rectum.  After  removing 
narrow  areas  of  the  rectum  the  results  are  very  unsatisfactory,  there  being  a  recur- 
rence of  the  stricture  at  the  site  of  suture.  In  the  anatomic  construction  of  the 
rectum  there  is  a  dense  connective-tissue  coat;  the  sigmoid,  having  less  of  this,  is  not 
so  disposed  to  subsequent  contraction.  When  the  rectum  is  exposed  by  Kraske's 
method,  the  removal  of  a  few  inches  more  of  bowel  adds  nothing  to  the  danger, 
while  the  substitution  of  the  sigmoid  adds  greatly  to  the  ultimate  success  of  the  pro- 
cedure. Insufficient  excision  is  generally  the  cause  of  recurrence  of  strictures  after 
operation. 


FISTULA  IN  ANO. 

Fistula  in  and  may  be  complete,  incomplete  (internal,  external),  complicated,  or 
complex  (Fig.  707).  Another  classification  of  great  importance  from  an  operative 
standpoint  is  fistulee  central  to  the  sphincter 
and  those  peripheral  to  it. 

A  complete  fistula  is  one  in  which  there  is  a 
communication  between  the  skin  and  the  rectal 
mucosa.  In  the  incomplete  variety  either  a 
canal  starts  from  the  mucosa  and  ends  blindly 
near  the  skin  (internal  blind),  or  it  starts  from 
the  skin  and  ends  near  the  mucosa  (external 
blind  fistula).  The  complicated  or  complex 
variety  is  where  there  are  many  sinuses  and 
many  external  openings,  with,  as  a  rule,  only 
one  internal  opening. 

These  abscesses  result  from:    (1)  Infection 
of  the  procteal  folds  or  anal  valves,  with  or 
without  incarcerated  foreign  bodies;   (2)  infec- 
tion of  the  hemorrhoidal  veins;   (3)  tuberculous  and  specific  ulcers;  (4)  peri-procteal 
dermoids;    (5)  peri-procteal  suppuration  from  lymphatic  infections  arising  in  the 
rectal  mucosa;    (6)  peri-anal  infections  extending  upward;   (7)  trauma. 

As  the  rectal  contents  are  always  under  tension,  with  gas  or  fecal  accumulations, 
and  as  these  tissues  are  constantly  in  motion,  and  in  a  favored  location  for  continued 
sepsis,  once  openings  are  made  they  are  slow  to  heal  and  fistulse  result.  The  tuber- 
culous fistula  may  be  either  primary  or  secondary  to  a  pulmonary  lesion;  the  latter 
is  very  common.  Allingham^  estimates  it  to  represent  10  to  14 per  cent,  of  the  patients 
with  fistula  in  ano.     Of  1632  cases,  234  had  antecedent  pulmonary  lesions.     Gant 

'  Allingham:  Op.  cit. 


Fig.  707. — Rectal  Fistul^e. 
a,  Blind  external;   b,  blind  internal; 
plate,  complicated. 


494 


INTESTINAL   SURGERY. 


had  a  similar  experience.     The  patency  of  the  fistula  may  be  established  either  by  a 
probe  or  by  the  injection  of  a  weak  solution  of  methylene-blue. 

Symptoms. — The  initial  symptoms  are  those  of  a  circumscribed  phlegmon 
with  a  subsequent  discharge  of  pus  either  from  the  rectum  or  from  some  point  on  the 
buttocks.  Pain  is  not  a  prominent  symptom,  except  just  preceding  the  rupture  of 
the  abscess.  When  the  opening  is  on  the  cutaneous  surface,  the  skin  is  inflamed,  and 
there  is  more  or  less  pruritus.  In  the  complete  variety  flatus  and  feces  often  escape 
through  the  opening.  In  the  course  of  time  there  may  be  incontinence  and  wasting; 
occasionally  hemorrhage. 

A  fistula  in  ano  rarely  heals  spontaneously, 
age;  (b)  impossibility  of  rest  to  the  part 
(an  essential  factor  for  repair);   (c)  con- 
tinued supply  of  infective  material  from 
the  feces. 

Treatment.  —  Preventive  treatment 
consists  in  the  early  and  thorough  drain- 
age of  all  peri-procteal  inflammatory  foci. 
PalHative  treatment,  though  of  little  bene- 
fit, may  have  to   be  resorted    to,   as   in 


This  is  due  to :   (a)  Imperfect  drain- 


FiG.  708. — Method  of  Incising  the  Sphincter. 
a,  Correct  way,  transverse;   b,  wrong  way,  oblique. 


Fig.  709. — Technic  of  Repair  of   Fistula  in  Ano. 

g,  d,  Grooved  director  inserted  in  fistula;  s,  sphincter; 

/,  finger  in  rectum. 


the  case  of  patients  who  decline  intervention  or  whose  condition  precludes  this. 

Operative. — General  or  local  anesthesia,  preferably  the  latter.  Of  first  rank  is 
the  sterile  water  anesthesia  of  Gant;  the  various  analgesic  solutions  may  be  effec- 
tively used. 

Incision. — After  a  thorough  preparation  of  the  field  of  operation,  the  patient  is 
placed  in  the  lateral  decubitus  and  the  fistula  incised  along  a  grooved  director.  In 
case  the  openings  do  not  correspond,  Tuttle  first  opens  the  tract  laterally,  external 
to  the  sphincter  until  its  fibers  stand  out  at  right  angles.  The  sinus,  after  being  in- 
cised, should  be  packed  and  allowed  to  heal  by  granulation.  All  divisions  of  the 
sphincter  should  be  transverse  and  not  oblique  (Figs.  708,  709). 


FISTULA    IN    ANO. 


495 


I'lu.   710. 


Showing  Method  of  Insertion    of    Deep 

AND  Superficial  Sutures. 


Incision  with  Closure. — This  method  consists  in  excising  the  fistulous  tract,  after 

which  the  deeper  structures  and  mu- 
cous margins  are  approximated  with 

catgut,  and  the  skin  with  silkworm-gut 

or  horsehair  (Fig.  710). 

Injection. — If  the  fistula  be  situated 

outside  the  internal  sphincter,  Goodsall 

and  Miles  advocate  an  injection  of  a 

6  per  cent,  solution  of  nitrate  of  silver, 

the  rectum  being  first  protected  by  an 

enema  of  olive  oil.     The  injections  are 

repeated,  if    necessary,   three   or  four 

times,   at    intervals    of    two    to    three 

weeks. 

Dilatation. — The  fistulous  tract  is 

gradually  dilated,   after   which    silver 

nitrate,  zinc  chlorid,  or  carbolic  acid  is 

apphed.     Heahng  takes  place  by  gran- 
ulation. 

Thermocautery. — The  Paquelin  cautery  may  be  used  in  place  of  the  zinc  chlorid 

or  the  nitrate  of  silver;  it  is  espe- 
cially applicable  in  the  tuberculous 
variety. 

Ligature. — This  method  is  not 
to  be  recommended.  It  is  based  on 
the  principle  of  pressure  necrosis  by 
an  elastic  ligature,  but  is  slow, 
painful,  and  presents  no  advantages 
over  the  methods  of  incision,  exci- 
sion, or  cauterization. 

Sequelae  of  Operations  for 
Fistulae. — The  principal  ones  are: 
(a)  Incontinence  of  feces;  (b)  in- 
continence of  flatus;  (c)  prolapse; 
(d)  continuous  ulceration. 

These  results  come  from — first, 
deep  division  of  the  sphincter,  with 
failure  of  reunion  of  its  ends,  which 
leaves  a  deep  groove,  often  un- 
covered by  epithelial  cells,  through 
which  gas  and  feces  leak;  second, 
multiple  divisions  of  the  sphincter 

leave  multiple  grooves  and  occasionally  paralysis  and  atrophy  of   the  individual 


Fig.  711. 


-Mayo  Robson's  Operation  for  Incontinence 
OF  Feces. 
a,  Anal  margin;    b,  sphincter  zone. 


496 


INTESTINAL   SURGERY. 


Sphincter  4ni 


sphincteric  segments.  In  the  tuberculous  fistulee  there  is  rarely  any  effort  at 
cicatrization  or  healing  unless  chemical,  thermal,  or  mechanical  removal  of  the 
granulations  has  been  effected.  The  types  of  operations  should  never  be  per- 
formed which  tend  to  sphincteric  incapacity,  as  fecal  incontinence  and  open  ulcers 
are  much  more  annoying  to  the  patient  than  the  fistula. 

Repair  in  Case  of  Incontinence. — If  after  an  operation  for  fistula  incontinence 
is  present,  it  may  be  reUeved  by  many  methods  of  repair.  The  one  suggested  by 
Mayo  Robson^  is  easy  of  appHcation  (Figs.  711,  712)  and  gives  fairly  good  results. 

It  consists  in  making  a  semi- 
lunar incision  about  the  anus 
at  the  muco-cutaneous  junc- 
tion, from  J  to  ^  inch  in 
depth.  This  should  be  car- 
ried deep  enough  to  expose 
the  sphincter  at  each  end. 
The  muco-cutaneous  flap  is 
then  displaced  centrally  and 
the  ends  of  the  sphincter 
united  with  the  deep  sutures. 
The  skin  incision  is  closed  by 
horsehair  or  silkworm-gut  and 
the  field  of  operation  protected 
from  infection  by  collodion. 

Another  way  is  to  make  a 
V-shaped  incision  with  the 
apex  at  the  skin  and  the  base 
toward  the  mucosa,  but  not 
incising  the  latter.  In  this 
way  the  mucosa  prevents  the 
access  of  infection  from  with- 
in the  bowel.  The  divided  margins  of  the  sphincter  are  freshened  and  approxi- 
mated with  kangaroo  tendon  or  chromoform-gut  sutures. 


Pig. 


712. — Mayo    Robson's    Operation    for    Incontinence    of 
Feces. 
Method  of  suture  insertion. 


PROLAPSUS  RECTI. 

By  this  we  understand  a  protrusion  of  the  rectum  through  the  anus;  it  may 
consist  of  the  mucous  coat  alone  or  all  the  coats  may  be  involved.  The  teriri  "pro- 
lapsus ani,"  though  frequently  used,  is  incorrect,  since  the  anus  is  merely  an  opening. 

The  etiologic  factors  vary  in  children  and  adults.  In  the  former  class  of  patients 
diarrhea,  constipation,  phimosis,  whooping-cough,  and  inanition  are  the  usual 
etiologic  factors.  In  adults  chronic  constipation,  proctitis  and  peri-proctitis,  en- 
larged prostate,  tumors  of  the  bladder,  rectum,  and  vagina,  and  lacerations  of  the 

'  Robson,  Mayo:  "An  Operation  for  Incontinence  of  Feces  Due  to  Relaxed  or  Paralyzed 
Sphincter  Ani,"  Practitioner,  Feb.,  1903. 


PROLAPSUS    RECTI. 


497 


perineum  are  the  most  common  causes.  Prolapse  of  the  rectum  may  also  form 
part  of  a  general  prolapse  of  the  pelvic  organs.  Relaxation  of  the  levator  ani  or 
sphincter  muscle,  once  started,  is  continually  overtaxed  by  the  intra-abdominal  pres- 
sure; once  started,  protrusion  of  the  rectal  mucosa  acts  as  a  colpeurynter  in  destroy- 
ing the  sphincteric  tension. 

Pathology. — The  prolapsed  peri-procteal  tissues  become  atrophied  in  time. 
The  bowel,  being  exposed  to  constant  irritation,  becomes  inflamed  and  may  finally 
ulcerate.  The  prolapse  may  include  the  sigmoid,  descending  colon,  and  even  a 
loop  of  the  small  intestine.  Partial  prolapse  is  more  common  in  childhood  (Fig. 
714);  complete  prolapse — of  all  the  coats — is  more  frequent  in  adults  (Tigs.  715,  716). 
Invagination  of  the  colon  and 
sigmoid  into  the  prolapsed 
rectum  is  not  uncommon; 
Leichtenstern  collected  no  less 
than  two  hundred  and  twenty 
cases.  In  forty-one  of  these 
the  tumor  protruded  through 
the  anus,  and  in  thirty-one  it 
could  be  palpated  in  the  rec- 
tum. 

The  diagnosis,  as  a  rule, 
presents  no  difficidty.  Occa- 
sionally, however,  a  prolapse 
of  small  size  may  be  mistaken 
for  a  polypus  or  hemorrhoids, 
and,  when  the  protrusion  is 
ulcerated,  it  may  be  inter- 
preted as  a  malignant  growth. 

In  addition  to  the  un- 
pleasant sensations  from  con- 
tact  of   the   mucosa  with   the 

clothing,  etc.,  the  burning  and  pain  are  almost  intolerable, 
attain  a  great  size — from  3  to  14  inches  in  diameter. 

Treatment. — In  partial  prolapse  Van  Buren's^  cauterization  method  is  an  ad- 
visable one.  The  patient  is  placed  in  the  knee-elbow  or  knee-chest  position  and 
the  prolapse  is  reduced.  Three  or  four  longitudinal  eschars  are  then  burned  tleep 
with  a  cautery  along  the  mucosa  down  to  the  muco-cutaneous  junction.  The  dis- 
advantage of  this  method  is  that  the  sphincter  may  remain  permanently  relaxed. 

In  complete  prolapse  a  number  of  procedures  are  available,  among  them  are: 

Lange's  Method. — The  patient  is  placed  in  the  knee-chest  position.  The  poste- 
rior wall  of  the  rectum  is  incised  from  the  lower  part  of  the  sacrum  to  the  anus  and 
all  of  the  coccyx  is  removed.     Then  catgut  sutures  are  passed  longitudinally  near 

1  Van  Buren,  W.  H.:    "Diseases  of  the  Rectum,"  New  York,  1881. 
VOL.  II — 32 


Fig.  713. — Congenital  Prolapsus  Recti;  Complete  Procidentia. 


The  protrusion  may 


498 


INTESTINAL    SURGERY. 


the  median  line,  and  through  the  muscularis  only,  in  this  way  infolding  the  posterior 
wall  of  the  rectum;  with  a  second  row  of  sutures  the  lateral  walls  are  brought  into 

apposition,  thus  burying  the 
longitudinal  sutures  and 
enfolding  the  wall  of  the 
rectum  still  farther.  The 
levator  ani  and  sphincter 
which  were  divided  are  now 
sutured  and  a  small  tube  is 
inserted  in  the  rectum  (Figs. 
718,  719,  720). 

Roberts'^  Method  (Fig. 
721).  —  The  patient  is 
placed  in  the  lithotomy 
position  and  the  prolapse 
reduced.  A  small  incision 
is  made  in  the  median  line 
of  the  perineum,  and  the 
finger  introduced  so  as  to 
free  the  rectum  from  the 
peri  -  procteal  tissue.  A 
scalpel  is  now  inserted  through  the  anus,  and  commencing  -\  inch  to  the  right  of 
the  median  line,  an  oblique  incision  is  made  through  the  skin  and  sphincter  down 


Fig.  714. — Prolapsus  Recti. 

Partial  rectal  paralysis;   anal  zone  normal,     a,  Anus;    b,  outer  wall  of 

bowel;  c,  inner  wall  of  bowel. 


Fig.  715. — Complete  Procidentia  (Ani  et  Recti). 

First  Degree. 
s,  Sphincter;    b,  outer  wall  of  bowel;    c,  inner  wall  of 
bowel;  m,  anal  mucosa. 


Fig.  716. — Complete  Procidentia,  Second  Degree. 

s,  Sphincter;  b,  outer  wall  of  bowel;  c,  inner  wall  of 

bowel;    sm,   sphincter   mucosae. 


to  the  first  small  incision.     A  similar  incision  is  then  made  on  the  opposite  side. 

The  triangular  piece  of  rectoperineal  tissue  is  removed  with  the  scissors;  the  wound 

'  Roberts,  J.  B.:    "Note  on  a  Method,  Probably  New,  of  Operating  for  Complete  Prolapse  of 
the  Rectum,"  Ann.  Surg.,  1890,  xi,  255. 


PROLAPSUS   RECTI. 


499 


and  sphincter  are  repaired  with  catgut  sutures;  a  tube  is  left  in  the  anococcygeal 
tissue.  By  following  this  procedure  there  is  danger  of  infection,  also  of  sacrificino- 
a  segment  of  the  sphincter,  thus  hazarding  the  ultimate  result. 

Treves'  Method. — With  the  patient  in  the  hthotomy  position  the  mucosa  of  the 
external  wall  is  divided  close  to  the  anal  margin.  This  mucous  cuff  is  reflected  down- 
ward and  the  bowel  is  divided  transversely  on  the  anterior  surface,  carefully  protect- 
ing the  peritoneal  cavity.  The  inner  tube  of  the  bowel  is  divided  and  the  circum- 
ference is  grasped  with  forceps.     The  gauze  is  removed  and  the  opening  into  the 


Fig.  717. — Musculature  of  the  Anococcygeal  Region. 


peritoneum  is  closed.     The  edge  of  the  divided  bowel  is  now  sutured  to  the  anal 
margin  of  the  rectum. 

Mikulicz's^  Method  (Fig.  722). — An  incision  an  inch  long  and  parallel  to  the  mar- 
gin of  the  anus  is  made  about  1  inch  from  the  same.  A  stitch  is  passed  and  tied, 
leaving  one  end  short;  then  with  the  other  long  end  a  continuous  suture  is  made 
through  the  circumference  of  the  rectum.     As  the  suture  proceeds  the  tube  is 

^  Bogdanik  (Mikulicz):  "Ueber  Mastdarmresection  wegen  ^'orfall,"  Arch.  f.  klin.  Chir.,  1894, 
xlviii,  847. 


500 


INTESTINAL    SURGERY. 


Fig.  718. — Lange's  Operation  for  Prolapsus  Recti. 
a,  Posterior  wall  of  rectum;    .5,  line  of  longitudinal  suture. 


divided  on  its  outer  aspect, 
so  that  the  suture  and  divi- 
sion are  both  finished  at  the 
same  time. 

Ganfs  Method,  or  the 
Wire  Operation  (Figs.  723, 
724). — The  rectum  is  in- 
cised longitudinally  on  its 
posterior  wall  and  the  coccyx 
excised.  The  former  is 
then  freed  from  its  attach- 
ments throughout  its  circum- 
ference; a  mattress  of  fine 
silver  wire  is  then  wrapped 
around  the  bowel  from 
below  upward;  the  bowel 
is  replaced  and  the  wound 
closed.  The  irritation  of 
the  wire  causes  firm  ad- 
hesions of  the  gut  to  the  an- 
terior surface  of  the  sacrum, 
and  a  firm  deposit  of  connec- 
tive tissue  around  the  wire. 


VerneuiVs  Method. — Place  the 
patient  in  an  exaggerated  Sims 
position.  Make  a  triangular  flap 
with  its  base  2  inches  broad,  and 
at  right  angles  to  the  tip  of  the 
coccyx,  extending  down  to  \  inch 
above  the  anal  margin.  Free 
this  flap  down  to  the  rectum  and 
then  reflect  it  up.  Four  sutures 
are  inserted  transversely  through 
the  muscles  of  the  rectum,  and 
brought  out  l2^  inches  on  the 
side  of  the  median  line.  This  is 
best  accomplished  with  the  eye 
of  the  needle  close  to  the  tip. 
The  highest  suture  should  come 
out  on  a  level  with  the  sacrococcy- 
geal junction,  and  each  succeed- 


FiG.  719. — Lange's  Operation  for  Prolapsus  Recti. 
a,  Posterior   wall  of   rectum;     h,  longitudinal   suture    tied; 
transverse  sutures  applied. 


PROLAPSUS    RECTI. 


501 


ing  one  on  a  level  with  the  respective  coccygeal  segments.  The  sutures  are  then 
brought  taut  and  tied  over  a  roll  of  gauze  to  prevent  pressure  necrosis.  Replace 
the  triangular  flap  and  drain.  (Priority  for  this  operation  really  belongs  to  George 
R.  Fowler. ') 

Gant's  Operation. — A  transverse  incision  1  j  inches  long  is  made  just  below  the 
coccyx;  the  rectum  is  freed  posteriorly  and  the  sphincter  divulsed.  The  bowel  is 
pushed  upward  and  brought  into  the  field  by  a  finger  introduced  into  the  rectum; 
a  longitudinal  incision  is  made  in  the  posterior  wall  for  some  2  to  4  inches, 
when  it  is  transformed  into  a  transverse  one;  the  cut  edges  are  now  united  by 
Lembert  sutures  of  fine  silk  or  catgut.  By 
this  method  the  bowel  is  shortened  several 
inches. 


Fig.  720. — Lange's  Operation  for  Prolapsus  Recti. 

a,  Posterior  wall  of  rectum;    s,  transverse  suture  tied  external 

to  longitudinal  puckering  suture 


Fig.  721. — Operation  for  Prolapsus  Recti 

BY  Robert's  Method. 

a.  Line  of  denudation;    6,  line  of  incision. 


Tuttle'-s^  Method  (Figs.  725,  726,  727,  728).— Place  the  patient  in  the  exaggerated 
Sims  position.  Make  a  semicircular  incision  2  inches  long  midway  between  the 
coccyx  and  the  anus,  extending  deeply  into  the  perirectal  cellular  tissue.  Free  the 
rectum  from  its  attachments  posteriorly,  either  with  the  finger  or  with  the  scissors. 
Curet  the  anterior  surface  of  the  sacrum;  an  assistant  then  invaginates  the  pro- 
lapsed bowel  through  the  incision  (Fig.  728).  The  posterior  wall  is  cleared  of  fat 
down  to  the  muscularis,  and  three  to  five  sutures  of  silkworm-gut  are  passed  trans- 
versely through  this  coat.     Then  with  a  long  Peaslee  needle  the  ends  of  the  sutures 

1  Fowler,  G.  R.:  "An  Improved  Technic  in  Amputation  of  Large  Rectal  Prolapse,"  Medical 
News,  1900,  Ixxvii,  879. 

2  Tuttle,  J.  P.:   "  Diseases  of  the  Rectum,  Anus  and  Pelvic  Colon,"  New  York,  1905. 


502 


INTESTINAL   SUEGERY. 
P- 


FiG.  722. — The  Line  of  Amputation  and  JIethod  of  Sutdre  in  Mikulicz's  Operation  for  Prolapsus  Recti. 
V,  V,  Peritoneal  cavity;   6,  inner  wall  of  intestine;   c,  outer  wall  of  intestine;   s,  s,  s,  line  of  suture. 


Fig.  723. — Showing  Gant's  Operation  for  Prolapsus  Recti. 
a,  6,  d.  Represents  line  of  incision  in  the  posterior  wall  of  the  rectum. 


PROLAPSUS    RECTI. 


503 


are  carried  through  the  rectum  and  the  sacral  margin,  and  brought  out  on  the  skin 
on  each  side  of  the  sacrum.  The  sutures  are  then  tied  over  a  pad  of  iodoform  gauze 
to  prevent  cutting  the  skin.  (They  should  be  left  in  place  for  ten  to  fourteen  days.) 
A  buried  circular  suture  of  kangaroo  tendon  is  passed  around  the  rectum  on  a  level 
with  the  upper  border  of  the  external  sphincter;  this  should  be  tied  tightly  enough 
to  constrict  the  finger  introduced  into  the  bowel.  The  semilunar  incision  is  closed 
with  deep  sutures  so  as  to  repair  the  rectococcygeus  and  the  sphincter  muscles. 

Peters'  Method. — The  rectum  in  this  method  is  reached  by  a  laparotomy.     It  is 
enfolded  longitudinally  by  passing  several  sutures  through  the  serous  and  muscular 
coats.     The  author  reports  a  cure  in  a  case 
of  two  years'  standing. 

Colopexy. — This  method  originated  with 
JeanneP  in  1889.  Technic:  An  incision  is 
made  as  if  for  an  artificial  anus,  and  the 
bowel  is  lifted  through  this  until  the  pro- 
lapse is  completely  reduced.  The  bowel  is 
then  fixed  by  stitches  to  the  abdominal  wall 
and  supported  by  a  sound  wrapped  in 
gauze.  The  author  made  an  artificial  anus 
on  the  sixth  day,  a  stool  occurred  on  the 
eighth  day,  and  the  sound  was  removed  on 
the  day  following.  Of  thirty  cases,  twenty- 
two  were  cured;  there  was  recurrence  in  four 
and  partial  recurrence  in  three.  No  deaths 
are  recorded  (Bryant). 

Siymoido'pexy  (Tuttle).  —  The  patient 
being  placed  in  the  Trendelenburg  position 
an  incision  is  made  through  the  left  rectus 
and  prolonged  upward  2^  inches  above  the 
pubes.  The  parietal  peritoneum  is  stripped 
on  either  side  and  the  sigmoid  is  pulled  out 
until  the  prolapse  disappears.     The  bowel  is 

then  fixed  by  stitching  the  muscular  band  of  the  sigmoid  to  the  wound.  The 
author  reports  seven  cases  with  no  recurrences. 

Murphy's  Method  (Figs.  729,  730,  731,  732).— The  writer  has  devised  a  very 
effective  and  practicable  procedure  in  subperitoneal  sigmoid  implantation.  The 
patient  is  placed  in  the  Trendelenburg  position,  the  peritoneum  is  opened  close  to  the 
pubis  and  through  the  outer  margin  of  the  left  rectus.  The  sigmoid  is  grasped  and, 
with  the  rectum,  is  drawn  up  as  high  as  it  will  come  with  moderate  traction.  The 
posterior  peritoneum  is  then  divided  from  the  border  of  the  pelvis  upward  for  a 
distance  of  5  inches  on  the  outer  side  of  the  ureter.  The  flap  is  next  freed  from  its 
posterior  attachments  in  an  outward  direction.  The  sigmoid  is  folded  into  the  de- 
1  Jeannel:    (quoted)  in  Bryant's  "Operative  Surgery." 


Fig.  724. — Line  of  Suture  for  Shortening 
THE  Wall  of  the  Rectum  (Gant's 
Method). 

a  and  d  are  brought  together  and  c  and  b  are 
separated,  giving  a  transverse  scar,  thus  short- 
ening the  distance. 


504 


INTESTINAL    SURGERY. 


nuded  peritoneal  zone,  and  is  secured  to  the  muscles  behind  the  peritoneum  by  a  con- 
tinuous catgut  suture.  The  flap  is  then  folded  centralward  around  the  sigmoid  and 
accurately  sutured  to  it  near  the  mesosigmoid.  The  under  surface  of  the  peritoneum 
becomes  fixed  and  the  sigmoid  in  turn  permanently  adheres  to  the  rectoperitoneal 
muscles  and  aponeurosis.     The  abdomen  is  then  closed. 


Fig.  725. — Tuttle's  Method  of  Rectopexy. 
Shows  line  of  incision  for  prolapsus  recti,    r.  Prolapsed  rectum;    i,  incision. 


HEMORRHOIDS. 

Hemorrhoids  or  piles  are  enlargements  or  varicosities  of  the  veins  in  the  mucosa 
and  submucosa  of  the  rectum,  generally  of  mechanic  origin,  producing  pain  and 
constipation,  and  prone  to  inflammation,  thrombosis,  ulceration,  and  periodic 
bleedings. 

The  usual  division  is  into  external  and  internal  hemorrhoids  and  cutaneous  tags. 
The  first  are  venous  dilatations  covered  by  skin;   internal  hemorrhoids  are  covered 


HEMORRHOIDS. 


505 


by  mucosa,  while  cutaneous  tags  are  redundant  folds  of  skin  without  enlarged  veins 
or  capillaries. 

The  condition  is  more  frequent  in  males  on  account  of  a  more  erect  posture. 
People  of  sedentary  life  are  usually  affected,  and  we  invariably  find  a  history  of  con- 
stipation. Pregnancy,  tumors  of  the  pelvis,  or  any  other  conditions  which  may  ob- 
struct the  flow  of  blood  from  the  pelvic  veins  are  also  etiologic  factors. 


Fig.  726. — Tuttle's  Method  of  Rectopexy. 
Shows  Peaslee  needle  passing  sutures  around  the  sacrum.    R,  Rectum;    P,  curved  Peaslee  needle. 


While  pain,  bleeding,  and  pressure  are  the  cardinal  symptoms,  they  are  not 
constant. 

Routes  of  Infection. — Before  entering  into  the  details  of  the  operative  pro- 
cedures, let  us  consider  the  three  principal  routes  of  post-operative  infection. 

(a)  The  infection  may  invade  the  perirectal  tissue,  lead  to  suppuration,  and  even 
to  a  true  ischiorectal  abscess. 


506 


INTESTINAL   SURGERY. 


(b)  Infection  may  travel  along  the  sacrum  behind  the  iliac  vessels,  up  to  the  pro- 
montory, and  infect  the  peritoneum,  thus  producing  peritonitis.  This  type  may 
also  cause  thrombosis  of  the  internal  or  common  iUac  vein. 

(c)  Extension  of  infective  phlebitis  and  thrombosis  into  the  middle  and  superior 
hemorrhoidal  veins,  even  to  the  portal,  is  not  at  all  uncommon,  and  may  result  in 
pylephlebitis. 


Sutures  tied  over  gauze  plug. 


Fig.  727. — Tuttle's  Method  of  Rectopexy. 

i,  Line  of  incision  closed;  s,  sutures  tied  over  gauze  plug;   p,  purse-string  suture 
-around  anus. 


This  type  of  infection  is  not  sufficiently  appreciated  by  operators;  it  originates  in 
the  hemorrhoidal  veins  through  transfixion  of  the  same  by  the  Ugature  of  the  operator. 
The  infection  travels  along  the  mesenteric  veins,  then  the  portal  vein,  and  finally 
invades  the  liver,  spleen,  etc.     The  following  case  is  illustrative: 

The  writer  saw  in  consultation  a  patient  who  had  been  operated  on  for  hemorrhoids 
five  weeks  previously.     He  was  discharged  from  the  hospital  and  had  been  walking 


HEMORRHOIDS. 


507 


about  for  some  time,  when  he  suddenly  developed  irregular,  recurrent  chills  and  fever; 
later  on  icterus  and  some  deep  abdominal  tenderness.  There  was  no  diarrhea  and 
no  tympany.  A  diagnosis  of  pylephlebitis  was  made.  The  patient  died,  and  a 
necropsy  performed  by  H.  G.  Wells,  of  the  University  of  Chicago,  revealed  abscesses 
of  the  liver  and  spleen,  thrombosis  and  suppuration  of  the  mesenteric  veins  down  to 


b--^. 


Fig.  728. — Invagination  of  Prolapsed  Bowel  Through  the  Posterior  Incision   (Tuttle's  Method). 
s,  Sphincter;   a,  line  of  division  of  skin  covering  coccyx;   6,  c,  shows  part  of  rectum  loosened  from  its  posterior 

attachment  by  blunt  dissection. 


the  point  of  transfixion  of  the  hemorrhoidal  vein.  The  infection  in  this  case  un- 
doubtedly started  from  the  transfixion  made  by  the  surgeon's  needle,  and  the  ligature 
allowed  the  admission  of  micro-organisms  into  the  vein  itself,  a  type  of  operation 
that  should  never  be  performed. 

Methods  of  Treatment. — Incision  and  evacuation  of  the  acute  thrombus  con- 


■^ 


\ 


Fig.  729. — Lfne  of  Incision   for   Sigmoidopexy   (Murphy). 


Fig.  730. — Murphy's  Sigmoidopexy  for  Prolapsus  Recti. 
b,  b,  b,  Shows  elevation  of  retroperitoneal  flap  and  subperitoneal  suture  line  in  sigmoid. 

508 


HEMOREHOIDS. 


509 


sists  in  incising  the  dilated  veins,  removing  the  clots  contained  therein,  and  packing 
the  cavity  with  gauze. 

Excision  with  ligation  is  a  clamping  of  the  hemorrhoidal  tumors  at  their  base, 
ligation  at  this  point,  and  amputation.  Much  pain  and  reflex  disturbance  can  be 
avoided  by  splitting  the  cutaneous  surface  and  peeling  it  backward  below  the  line 
of  ligation.  The  vitality  of  the  stump  at  the  point  of  ligation  should  be  completelv 
destroyed  by  the  crushing  effect  of  the  clamp;  this  diminishes  the  subsequent  pain 
and  destroys  the  reflex. 

Allingham's  Method. — The  tumors  are  exposed  by  a  rectal  speculum;  they  are 
then  grasped  one  by  one,  dissected  from  their  apex,  and  finally  ligated  at  their  base. 

Whitehead's^  Method  (Figs.  733,  734, 
735). — The  mucosa  is  incised  circularly  at 
its  junction  with  the  skin;  then  the  area 
containing  the   hemorrhoids  is  dissected 


Fig.  731. — Murphy's  Sigmoidopexy. 

a,  a,  a,  Shows  line  of  suture  of  retroperitoneum  over 

embedded  sigmoid. 


Fig.   732. — Murphy's  Sigmoidopexy'. 
ms.  Mesosigmoid;  s,  wall  of  sigmoid;  c,  reflected  retroperi- 
toneal suture  over  bowel. 


free  beyond  the  zone  of  venous  dilatation  and  above  the  sphincteric  level.  A  cir- 
cular amputation  is  made  at  this  point;  the  mucosa  above  is  freed  for  a  short 
distance  upward ;  it  is  then  drawn  down  and  sutured  to  the  cutaneous  margin 
throughout  the  entire  circumference. 

We  do  not  indorse  this  method,  as  it  is  occasionally  followed  by  stricture  and 
pruritus.  The  principal  objection,  however,  is  because  it  removes  the  small  zone 
of  skin  containing  the  papillae,  and  the  papillary  reflex  is  an  important  element  in 
the  control  of  defecation.  In  this  operation  the  vessels  are  simply  twisted,  not  ligated. 
In  three  hundred  cases  Whitehead  did  not  have  a  single  post-operative  hemorrhage. 
He  uses  carbolized  silk  ligatures. 

1  Cripps,  Harrison  (Whitehead,  W.  L.):  "Prolapse  of  the  Upper  into  the  Lower  Part  of  the 
Rectum  without  External  Protrusion,"  Brit.  Med.  Jour.,  1887,  i,  447. 


510 


INTESTINAL   SURGERY. 


Earl's  modification  of  Whitehead's  operation  is  as  follows:    The  hemorrhoidal 

dilatations  are  grasped  and  brought 
down  and  the  mucosa  is  incised  above 
them.  With  a  special  forceps  the 
veins  are  seized  and  excised,  and  the 
openings  sutured  over  the  forceps,  the 
latter  not  being  removed  until  the 
suturing  is  finished.  In  other  words, 
this  modification  consists  in  removing 
the  hemorrhoids  and  stitching  up  the 
mucosa  without  a  circular  resection. 
Ligation. — Coates'  Method, — The 
hemorrhoids  are  grasped  with  forceps 
and  brought  down.  A  clamp  is  then 
applied  to  the  pedicle  and  catgut 
sutures  passed  around  this  are  tied. 

Mitchell's  Method.— The  hemor- 
rhoid is  clamped  and  amputated;  a 
catgut  suture  hardened  in  formalin  is 
passed  beneath  the  upper  end  of  the 
clamp  and  tied;  one  end  is  cut  short, 
and  with  the  other  a  continuous  whip- 
stitch suture  is  made  over  the  clamp. 
The  clamp  is  then  withdrawn  and  the  suture  tied. 


Fig.  733. — First  Step  of  Operation  for  Hemorrhoids 
Rectal    speculum    inserted,     sphincter    dilated.     Hemor- 
rhoidal tumors  seen  through  speculum. 


Fig.    734. — Modified    Whitehead    Operation    for 

Hemorrhoids. 

o,  Clamp  grasping  individual  hemorrhoids. 


Fig.  735. — Whitehead's    Modified    Operation   for 

Hemorrhoids. 
a.  Hemorrhoid;  6,  cutaneous  surface;  c,  mucous  sur- 
face. 


HEMORRHOIDS. 


511 


Mathews'^  Method. — Tumors  of  small  size  are  simply  ligated.  The  larger  ones 
are  grasped  by  forceps;  a  silk  ligature  in  a  round  needle  is  then  passed  through  the 
base  and  tied,  after  which  the  tumor  is  excised  (Fig.  736). 

Ricketts'  Submucous  Ligature. — A 
needle  curved  to  somewhat  more  than  a 
semicircle  is  passed  around  the  hemor- 
rhoid in  the  submucous  tissue.  The 
ligature  (usually  a  kangaroo  tendon)  is 
tied.  As  a  result  the  tumors  contract 
and  disappear  in  a  few  weeks  (Figs.  737, 
738). 

Gushing  has  reappHed  the  old  method 
of  Chassaignac,  which  consists  in  crush- 
ing the  tumors  with  the  ecraseur.  In 
1880  the  method  was  highly  praised  by 
Pollock,  of  London. 

Chemical. — Cauterization  which  orig- 
inated with  Cusack,'  of  DubKn,  in  1843,  consists  in  cauterizing  the  pile  tumors 
with  nitric  acid.     This  author  claimed  that  the  method  was  especially  useful  in 
capillary  hemorrhoids. 


Fig.  736. — Mathews'  Method  of  Partial  Sub- 
cutaneous AND  Submucous  Ligation  of 
Hemorrhoids  with  Excision  (Bryant). 


Fig.  737. — Complete  Submucous  and  Subcutaneous 
Ligation  of  Hemorrhoid  without  Excision 
(Ricketts). 


Fig.  738. — Second  Step  of  Operation  (Ricketts). 


Hamilton  advised  passing  needles  coated  with  fused  nitrate  of  silver  through  the 
hemorrhoids.  (These  chemical  cauterization  methods  are  not  to  be  recom- 
mended.) 

1  Mathews,  J.  M.:   "Diseases  of  the  Rectum  and  Anus,"  New  York,  1903. 

2  (Cusack)  Houston,  John:  "An  Essay  on  the  Use  of  Nitric  Acid  as  an  Escharotic  in  Certain 
Forms  of  Hemorrhoidal  Affections,"  DubHn  Jour.  Med.  Sci.,  1843,  xxiii,  94. 


512 


INTESTINAL   SURGEEY. 


Injection  Method. — This  seems  to  have  originated  with  Mitchell,  of  Clinton,  111., 
in  1871.  Various  solutions  are  used,  but  carbolic  acid  is  the  principal  one.  This 
method  is  very  dangerous,  and  many  deaths  have  been  reported  from  its  use. 
Among  the  more  serious  accidents  following  this  procedure  are  stricture,  embolism, 
and  carbolic  acid  intoxication. 

The  American  o'peration,  which  is  a  modification  of  Whitehead's  method,  con- 
sists in  the  removal  of  the  skin  all  around  the  anus;  then,  after  dissecting  the  hemor- 
rhoids out,  the  mucous  edges  are  sutured  to  the  cutaneous  margins  so  as  to  produce 

a   slight   ectropion   of    the   mucosa. 
The    reasons   for   opposing  White- 
head's operation  hold  good  and  are 
even     accentuated     in     this 
^      modification.     The  removal 
of    the   perianal    skin  occa- 
sionally  leads    to   tactile  loss  of 
spliincteric   control.     The  injection 
method  and  the  American    method 
have    been    confounded    by    many 
authors. 

The  clamp  and  cautery  method 
(Fig.  739)  is  one  of  the  most  simple  as 
well  as  one  of  the  most  efficient  for 
hemorrhoids.  First  the  sphincter  is 
forcibly  dilated  to  a  maximum  de- 
gree, producing  a  temporary  paraly- 
sis. The  highest  point  of  each  hemor- 
rhoidal tumor  is  then  grasped;  the 
muco-cutaneous  margin  is  incised 
for  h  inch  with  scissors  the  points  of 
which  are  pushed  beneath  the  skin 
and  spread,  thus  freeing  it  from  the 
hemorrhoids.  The  clamp  is  now 
placed  on  the  sides  of  the  hemor- 
rhoids in  a  line  radiating  from  the 
center  outward,  including  the  hemorrhoidal  vein  and  as  much  of  the  mucosa  central- 
ward  as  it  is  desired  to  remove.  The  clamp  is  closed  so  as  not  to  include  the  skin. 
The  hemorrhoid  is  excised  with  the  scissors  on  the  level  with  the  clamp  and  the 
stump  cauterized  with  the  pyrography  cautery  previously  alluded  to.  The  clamp 
is  then  removed  and  the  process  repeated  until  all  the  tumors  are  excised.  The 
skin  flaps  occasionally  appear  as  tags  when  the  healing  is  complete.  If  they  are 
long  or  annoying,  they  may  be  clipped  off  after  hydroanalgesia  (Gant).  They  are 
extremely  serviceable,  however,  in  the  cases  of  keloid  tendency  to  stenosis. 

After  enumerating  all  these  procedures  it  is  very  natural  to  ask  which  one  should 


Fic;.     I  39. (JPKRATION     BY    THK    ClAMP    MeTHOD. 

a,  Clamp  on  the  hemorrhoidal  dilatation;  h,  scissors 
applied  parallel  and  close  to  the  clamp,  ready  to  cut  off 
the  hemorrhoidal  dilatation;  c,  thermocautery. 


HEMORRHOIDS.  513 

be  selected.  In  the  writer's  opinion,  the  operation  of  election  should  be  either  the 
clamp  and  cautery,  or  one  in  which  the  veins  are  first  encircled,  ligated  (but  not  trans- 
fixed), and  then  amputated. 

Sequelae  after  Operations  for  Hemorrhoids.— Immediate,  dysuria;  secon- 
dary, hemorrhage;  infections  (peri-rectal,  peritoneal,  portal),  erysipelas.  Later, 
fistulse,  ulceration ;   fissure,  stricture,  and  recurrence  of  the  hemorrhoids. 

Dysuria  is  relieved  by  a  full  dose  of  morphin  hypodermically.  Secondary 
hemorrhage  should  always  be  treated  by  Kgature  or  suture;  never  by  tampon  or 
styptics. 

Infection  can  be  avoided  if  care  be  taken  in  (1)  preparation  of  field  of  operation; 
(2)  care  of  patient.  A  recumbent  position  is  favorable  for  convalescence;  it  is  not 
indispensable,  however.  Healing  is  slow  and  free  from  pain.  Fistula  and  fissures 
do  not  appear  if  proper  dressings  are  applied  after  the  operation.  Stricture  is  a 
sequel  of  the  removal  of  too  much  cutaneous  or  submucous  fibrous  tissue.  True 
recurrences  after  an  efficient  operation  are  very  uncommon.  The  little  tags  of  skin 
are  frequently  erroneously  considered  by  the  patients  (and  occasionally  by  ill-in- 
formed physicians)  as  a  return  of  the  hemorrhoids.  The  bowels  should  move  daily 
after  the  operation. 


VOL.  II — 33 


CHAPTER  XXXV. 

OPERATIONS  FOR  DISEASES  OF  THE  VERMIFORM  APPENDIX. 

By  Howard  A.  Kelly,  M.D.,  and  Elizabeth  Hurdon,  M.D. 

APPENDICITIS. 

History. — Appendicitis  may  be  called  a  modern  disease.  Thirty  years  ago  it 
was  regarded  with  interest  as  a  rare  condition,  but  today  it  is  known  to  be  the  most 
common  abdominal  affection  occurring  in  young  individuals.  While,  however, 
there  was  a  definite  increase  in  the  number  of  cases  during  the  recent  large  epi- 
demics of  influenza,  the  apparently  remarkable  increase  in  its  prevalence  during 
the  last  two  decades  is  mostly  due  to  more  accurate  diagnosis.  For  example,  the 
statistics  of  the  German  army,  which  show  a  great  increase  in  the  number  of  cases 
of  appendicitis,  show  a  corresponding  decrease  in  other  abdominal  affections.^ 

Primary  disease  of  the  appendix  was  first  clearly  recognized  by  Mestivier,^ 
who,  in  1761,  described  a  case  of  right  iliac  abscess  which  he  attributed  to  inflam- 
mation of  the  appendix  caused  by  a  pin  in  its  lumen.  It  was  not,  however,  until 
seventy  years  later  that,  following  the  publications  of  Louyer-Villermay  ^  and 
Melier,*  the  susceptibility  of  the  appendix  to  primary  disease  was  generally  recog- 
nized; and  even  then,  notwithstanding  the  clear  exposition  of  Melier,  who  recog- 
nized the  existence  of  chronic  as  well  as  acute  inflammation  of  the  appendix,  the 
cecum  was  believed  to  be  the  usual  source  of  disease  of  the  right  iliac  region. 
During  the  next  sixty  years  an  appreciation  of  the  important  role  played  by  the 
appendix  in  the  production  of  many  different  abdominal  affections,  especially 
those  of  the  right  lower  quadrant,  was  gradually  evolved,  and  was  finally  estab- 
lished by  the  classic  work  of  Reginald  H.  Fitz,  ^  published  in  1886.  Today  there  is 
probably  no  other  surgical  affection  so  well  understood. 

The  surgical  treatment  of  appendicitis,  as  it  is  now  practised,  is  a  development 
of  the  last  twenty  years.  Its  evolution  may  well  be  regarded  as  the  most  notable 
achievement  of  modern  surgery,  and  with  it  the  names  of  American  physicians, 

1  Karrenstein:    Deutsch.  Ztschr.  f.  Chir.,  Leipz.,  1906,  Ixxxiv,  63. 

^  Mestivier :  "Observations  sur  une  tumeur  situee  proche  la  region  ombilicale  du  cote  droit," 
etc.,  Jour,  de  med.,  chir.,  et  phar.,  1759,  torn.  10,  441. 

^  Louyer-Villermay:  "Observations  pour  servier  a  I'histoire  des  inflammations  de  I'appen- 
dice  du  cecum,"  Arch.  gen.  de  med.,  1824,  tom.  5,  246. 

*  Melier:  "Memoire  et  observation  sur  quelques  maladies  de  I'appendice  cecale,"  Jour, 
gen.  de  med.,  1827,  tom.  100,  317. 

^  Fitz,  R.  H.:  "Perforating  Ulcer  of  the  Vermiform  Appendix  with  Special  Reference  to 
its  Early  Diagnosis  and  Treatment,"  Am.  Jour.  Med.  Sci.,  1886,  xcii,  32;  "The  Relation  of 
Perforating  Inflammation  of  the  Vermiform  Appendix  to  Perityphlitis,"  N.  Y.  Med  Jour.,  1888, 
xlvii,  505. 

514 


APPENDICITIS.  ■  515 

including  those  of  Fitz,  Morton,  Sands,  Fowler,  McBurney,  Deaver,  Murphy, 
Mynter,  Morris,  et  al.,  are  especially  associated.  Incision  and  evacuation  of  right 
iliac  abscesses  had  been  practised  from  the  beginning  of  the  Christian  era,  but  it 
was  not  until  1848  that  the  advisability  of  incising  tumors  in  the  right  ihac  fossa 
before  fluctuation  occurred  was  considered.  Hancock,^  in  the  year  1848,  in  the  case 
of  a  woman  with  symptoms  of  spreading  peritonitis,  associated  with  a  hard,  cord- 
like swelling  in  the  right  iliac  region,  opened  the  abdomen  and  evacuated  a  Cjuantity 
of  turbid  fluid  and  false  membrane  from  the  peritoneal  cavity.  Fifteen  days  later 
two  fecal  concretions  were  found  in  the  wound,  and  after  their  removal  a  rapid 
recovery  ensued.  This  method  of  treatment,  however,  did  not  come  into  general 
use  until  the  publication  in  1867  of  ^Yillard  Parker's^  paper  emphasizing  the  impor- 
tance of  early  incision  and  drainage.  The  introduction  of  antisepsis,  the  year  follow- 
ing the  pubhcation  of  Parker's  paper,  was  probably  an  important  factor  in  the  rapidly 
gained  popularity  of  the  operation,  which,  in  the  next  fifteen  years,  reduced  the 
mortality  of  perityphhtis  from  47  per  cent,  to  15  per  cent.  A  growing  recognition 
that  the  appendix  jper  se  was  the  source  of  most  affections  of  the  right  abdomen,  and 
that  practically  all  cases  of  so-called  perityphlitis  were  due  to  appendical  disease, 
finally  led  up  to  a  further  important  advancement  in  its  treatment,  which,  from  then 
on,  was  directed  to  the  removal  of  the  appendix  itself  as  the  source  of  the  disease. 
In  1884,  Mikulicz^  advocated  cutting  down  upon  the  appendix  as  soon  as  a  diagno- 
sis was  tolerably  certain,  tying  it  above  the  seat  of  the  perforation,  and  removing  any 
concretive  or  decomposing  material  in  the  neighborhood.  Kronlein*  in  the  same 
year  had  an  opportunity  of  carrying  out  this  plan  of  treatment  and  was  the  first  to 
resect  the  appendix.  In  1885,  Symonds'^  did  an  interval  operation  in  a  case  of  re- 
current appendicitis,  cutting  down  upon  a  small  hard  mass  extraperitoneally  and 
removing  a  concretion,  but  leaving  the  appendix  m  situ.  In  the  year  1886  Morton^ 
successfully  removed  a  perforated  appendix,  doing  the  first  deliberately  planned 
operation  for  appendicitis  comphcated  with  peritonitis.  About  the  same  time 
Treves^  successfully  operated  upon  a  case  of  relapsing  appendicitis,  but  finding 
that  he  could  correct  the  distortion,  did  not  remove  the  appendix.  Fitz's  article, 
which  has  since  become  classic,  cleared  up  the  entire  subject,  establishing  upon  a 
sound  basis  the  important  role  played  by  the  appendix  in  the  causation  of  right 
iliac  disease,  and  urging  the  necessity  of  early  operative  interference.  In  this 
paper  the  name  appendicitis  was  first  used,  the  author  originating  the  new  term  for 

'  Hancock:     "Diseases  of  the  Appendix  Cseci  cured  by  Operation,"  Lancet,  1848,  ii,  380. 

2  Parker,  W.:  "An  Operation  for  Disease  of  the  Appendix  vermiformis  ceci,"  N.  Y.  Med. 
Rec,  1867,  ii,  25. 

^Mikulicz:  "Ueber  Laparatomie  bei  Magen-  u.  Darmperforation,"  Sammlung.  khn.  Vort- 
rage,  1885,  No.  262. 

*  Kronlein:  "Ueber  die  operative  Behancllung  der  acuten  diffusen  jauchig-eitrigen  Peritonitis," 
Arch.  f.  khn.  Chir.,  1886,  Bd.  33,  507. 

5  Symonds:  "On  a  case  in  which,  at  the  suggestion  of  the  late  Dr.  Mahomed,  a  calculus  was 
removed  from  the  vermiform  appendix  for  the  relief  of  recurrent  typhlitis,"  Lancet,  1885,  i,  895. 

8  Morton,  T.  G.:  "Case  of  Exploratory  Laparotomv  followed  by  Appropriate  Remedial 
Operation,"  Trans.  Coll.  Phys.  and  Surg.  Phila.,  1887. 

'  Treves,  F.:  "Relapsing  Typhlitis  Treated  by  Operation,"  Med.  and  Chir.  Trans.,  London, 
1888,  vol.  Ixxi,  165;   Lancet,  1888,  i  527. 


516 


01 


ERATIOXS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 


the  purpose  of  calling  attention  U>  appendical  inflammation  as  the  primary  lesion 
and  of  discouraging  the  prevailing  vieiv  that  the  cecum  was  involved  to  any  extent. 
From  this  time  onward  the  view  that  appendicitis  was  a  surgical  disease  from  its 
very  inception  gradually  gained  ground,  and  is  now  generally  accepted. 


III..   7  10.     .\ii,\fjnM.\L   Position   op  the  Appendix. 
The  cecum  and  the  pio.xinial  part  of  the  appendix  have  become  adherent  to  the  posterior  abdominal  wall  before 

their  de.scent  into  the  right  iliac  fossa. 


Anatomy  and  Physiology. — A  study  of  the  embryology  of  the  appendix  .shows 
it  to  1k',  l)oth  structurally  and  morphologically,  merely  a  part  of  the  general  cecal 
pouch  which  lias  remained  in  an  early  stage  of  development.     In  the  adult  it  appears- 


APPENDICITIS. 


517 


as  a  worm-like  appendage  continuous  with  the  cecum,  averaging  S.o  cm.  in  length 
and  with  a  generally  uniform  diameter  of  6  mm.  Marked  variations  in  length, 
however,  are    noted,  some  appendices 


others  30  cm.  or 


-^^- 


being  less  than  1  cm 
more  in  length. 

It  possesses  an  outer  longitudinal 
and  an  inner  circular  muscular  coat,  a 
well-developed  submucosa,  and  a  mu- 
cous membrane.  In  young  individuals 
the  mucous  membrane  is  conspicuously 
rich  in  lymphoid  tissue,  while  its  epithe- 
lium is  largely  composed  of  goblet  cells. 
In  older  persons  the  lymph-follicles  are 
smaller  and  fewer  in  number,  and,  as  a 
rule,  retrogressive  changes  are  pro- 
nounced throughout  the  entire  organ. 
In  a  considerable  percentage  of  cases 
the  tip  is  obliterated  and  sclerotic 
changes  are  marked  in  the  submucosa 
and  in  the  vessel  walls. 

The  vascular  supply  of  the  appen- 
dix is  usually  derived  from  the  ileocolic 
or  the  posterior  ileocecal  artery.  In  a 
few  cases  it  comes  from  the  anterior 
ileocecal  artery.  The  peritoneal  reflec- 
tion containing  the  blood-vessels  forms 
the  mesappendix.  The  main  veins  for 
the  most  part  empty  directly  into  the 
portal  system,  and  by  way  of  small  collat- 
eral channels  described  by  Retzius  and 
Sappey  an  indirect  communication  with 
the  general  systemic  circulation  may  also 
exist. 

The  lymphatics  of  the  appendix 
drain  into  the  glands  of  the  ileocolic 
angle. 

The  question  of  the  function  of  the 
appendix  possesses  considerable  interest 
now  that  so  large  a  portion  of  the  popula- 
tion is  being  deprived  of  this  organ  in 
early  life.  That  it  is  actively  function- 
ating, in  early  life  at  least,  is  evident  from  its  structure,  but  there  is  no  convincing 
evidence  to  be  obtained  from  a  study  of  its  structure  or  its  physiologic  activity,  or 


Fig.  741.— Retrocolic  Appendix  with  its  Tip  Held 
Adherent  to  the  Lower  Pole  of  the  Kidney. 


518  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 

from  analogy,  to  show  that  it  has  a  specific  function  of  its  own  distinct  from  that  of 
the  cecum.  Macewen's^  interesting  observations  prove  that  the  appendix  pours  out 
an  abundant  alkahne  secretion,  which  Pawlow  suggests  may  be  of  the  nature  of  an 
enterokinase.  It  is  a  favorable  medium  for  the  growth  of  intestinal  flora,  a 
superabundant  growth,  however,  being  probably  controlled  by  the  lymph  elements. 

Topography. — A  definite  appendix  is  visible  about  the  end  of  the  eighth  week 
of  intrauterine  life,  just  before  the  intestine  recedes  into  the  abdomen.  Within 
the  abdomen  the  cecum  and  appendix  at  first  lie  near  the  umbilicus,  while  the  entire 
large  intestine  lies  to  the  left  of  the  median  line.  In  the  course  of  the  normal  rota- 
tion of  the  intestine  the  cecum  and  appendix  are  then  pushed  upward,  anterior  to  the 
duodenum,  until  they  lie  just  beneath  the  liver  near  the  middle  line,  then  gradually 
move  toward  the  right  hypochondriac  region,  and  at  about  three  to  four  months 
lie  immediately  anterior  to  the  right  kidney.  From  about  the  fourth  to  the  seventh 
month,  sometimes  not  until  birth,  the  cecum  and  appendix  gradually  descend  into 
their  final  position  in  the  right  iliac  fossa.  If,  however,  during  rotation  and  descent, 
any  part  of  the  ileocecal  apparatus  becomes  adherent  to  neighboring  structures,  it 
may  not  reach  the  iliac  fossa,  but  remains  in  the  right  upper  quadrant,  attached 
to  the  kidney,  gall-bladder,  or  some  other  structure  in  its  vicinity.  In  rare  instances 
the  normal  rotation  and  the  development  of  the  ascending  colon  fail  to  take  place, 
and  the  cecum  and  appendix  may  be  found  in  the  mid-line  of  the  abdomen  or  entirely 
in  the  left  side. 

The  location  of  the  point  of  origin  of  the  appendix  depends  upon  the  topography 
of  the  cecum.  Two  main  locations,  however,  are  recognized:  (a)  behind,  and  (b) 
in  front  of  the  lower  margin  of  the  cecum.  The  development  of  these  positions 
depends  upon  the  time  at  which  the  mesocolon  fuses  with  the  posterior  abdominal 
wall;  early  fusion,  the  subsequent  descent  of  the  cecum  then  affecting  mainly  the 
lateral  and  anterior  portions,  producing  the  first  form,  and  late  fusion  the  second. 
The  first  position  is  by  far  the  most  frequent,  Treves  placing  it  at  90  per  cent.  If 
the  point  of  origin  is  retrocecal,  the  appendix  may  be  either  intraperitoneal  or  extra- 
peritoneal, according  as  the  level  of  the  peritoneal  reflection  is  above  or  below  it. 
If  it  is  above,  the  appendix  usually  occupies  a  retrocolic  or  retrocecal  pocket.  The 
prececal  appendix  is  always  intraperitoneal,  and  usually  hangs  directly  downward 
or  is  freely  movable  among  the  coils  of  small  intestine.  In  case  of  disease  the  prececal 
position  is  especially  dangerous,  whereas  the  retrocecal  appendix  is  most  favorably 
placed  for  the  isolation  of  the  infective  process. 

The  appendix  may  point  in  almost  any  direction,  but  most  frequently  it  is  hidden 
behind  the  cecum.  The  most  common  positions  and  their  relative  frequency  are 
approximately  as  follows : 

Behind  the  ileocecal  junction about  40  per  cent. 

Ascending  vertically  behind  or  lateral  to  the  cecum  and  colon 25  to  30  per  cent. 

Descending  or  pelvic 25  to  30  per  cent. 

An  important  feature  in  the  topographic  anatomy  of  the  appendical  region  is  the 
^  Macewen,  Sir  William:     "The  Function  of  the  Appendix  and  Caecum,"  Lancet,  1906,  i. 


APPENDICITIS. 


519 


presence  of  the  various  peritoneal  folds  and  pockets.  They  may  be  divided  into 
the  prececal  and  retrocecal  or  subcecal  folds  and  pockets.  The  former  He  in  front 
of  and  to  the  left  of  the  cecum  and  include  the  ileocolic  and  ileocecal  folds  and  the 
mesappendix,  separating  the  ileocoHc,  superior  and  inferior  ileocecal  fossae;  the 
latter,  situated  behind  the  cecum,  form  the  internal  and 
external  retrocecal  fossae  and  the  retrocolic  fossa.  The 
appendix  is  often  hidden  in  one  of  these  pockets. 

Pathology. — The  diseases  which  may  attack  the  ap- 
pendix are :  simple  inflammation,  specific  infections,  new- 
growths. 

Inflammatory  affections  of  the  appendix  may  be  divided 
into  acute,  chronic,  and  residual 
conditions.  The  infective  process 
may  be  limited  to  the  appendix, 
may  spread  to  the  general  peri- 
toneum, or  may  produce  a  metastatic 
or  general  infection. 

Acute  appendicitis  in  practically 
all  cases  is  characterized  by  a  diffuse 
inflammation  of  all  the  tissues  of 
the  appendical  walls.  The  disease 
is  rarely  limited  to  the  inner  coats. 
The  organ  in  the  early  stages  of  the 
attack  is  turgid,  injected,  and 
slightly  rigid ;  the  superficial  vessels 
are  dilated  and  tortuous;  the  peri- 
toneal   surface   is  usually  diffusely 

reddened,  sometimes  appears  finely  granular,  and  may  be 
flecked  with  a  serofibrinous  or  fibrinous  exudate  (Fig.  743). 
Discolored  areas  of  beginning  gangrene  and  suppuration  are 
sometimes  found  within  the  first  few  hours  of  the  attack; 
the  organ  may  even  be  completely  gangrenous.  Early 
gangrene  in  appendical  inflammation  may  be  due  to  pre- 
existing vascular  degeneration,  superimposed  upon  which  the 
acute  inflammatory  reaction  produces  complete  obstruction 
of  the  circulation.  Perforations,  of  pin-point  size  or  involv- 
ing the  whole  circumference,  take  place  at  any  period, 
marking  the  onset  of  symptoms  or  occurring  during  the 
apparent  subsidence  of  the  attack.  In  some  of  the  most 
rapidly  fatal  cases  the  appendix  may  show  nothing  beyond  a  diffuse  reddening 
and  edema  of  the  tissues.  The  canal  may  be  patulous  throughout,  containing 
merely  a  little  mucopurulent  exudate;  the  mucosa  is  swollen  and  injected,  and 
minute  ulcerations  usually  may  be  found.     In  other  cases  the  canal  is  obstructed 


Fig.  742. — Acute  Appendi- 
citis. 
The  appendix  and  mesap- 
pendix are  swollen  and  hemor- 
rhagic. A  few  vascular  ad- 
hesions are  attached  to  the 
serosa  and  a  hemorrhagic  lob- 
ule of  fat  to  the  tip  of  the  ap- 
pendix. 


Fig.  743. — Acute  Appen- 
dicitis. 
The  whole  appendix 
is  intensely  congested;  the 
proximal  third  is  distended 
with  pus  and  at  b  shows  an 
area  of  beginning  gangrene. 
At  a  the  appendix  is 
sharply  kinked  and  held 
in  this  position  by  old  ad- 
hesions; the  convex  sur- 
face of  the  kink  is  gan- 
grenous. (Case  of  G.  Beck.) 


520 


OPERATIONS   FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 


near  the  cecum  and  the  part  beyond  is  distended  with  pus  and  hned  with 
granulations  or  partially  necrotic  material.  Porter^  describes  a  case  in  which  the 
appendix,  obstructed  at  its  origin  by  a  concretion,  was  distended  with  pus  and 
gas — pyopneumo-appendix. 

The  spread  of  the  infective  process  may  occur  directly  through  the  walls  of  the 
appendix  or  by  means  of  a  perforation,  producing  a  circumscribed,  spreading, 
or  general  peritonitis;  or  it  may  occur  by  way  of  the  lymph  or  blood-channels 
through  the  intact  walls,  and  cause  a  metastatic  or  general  infection. 

Peritonitis  due  to  appendicitis  may  be  serofibrinous,  septic,  or  purulent,  and 

may  be  localized,  spreading,  or  general. 

Suppurative  Periappendicitis  (Circumscribed  Puru- 
lent Peritonitis  or  Periappendical  Abscess). — The 
localization  of  a  periappendical  abscess  varies  accord- 
ing to  the  direction,  position,  and  length  of  the 
appendix,  whether  it  is  intraperitoneal  or  extraperi- 
toneal; and  the  situation  of  the  most  severe  lesion  in 
the  appendix,  whether  in  the  middle,  base,  or  tip. 
Not  infrequently  the  appendix  is  hidden  in  a  perito- 
neal pocket  which  is  especially  favorable  for  the 
walling  off  of  the  suppurative  process.  The  natural 
barriers  of  the  abdomen,  as  pointed  out  by  Mikulicz, 
also  tend  to  determine  the  direction  in  which  the 
abscess  may  spread.  The  posterior  abdominal  wall 
presents  three  well-defined  cavities  in  which  pus  is 
apt  to  collect — the  right  and  left  iliac  fossse  and  the 
pelvis.  The  abdomen  is  further  divided  into  a  supra- 
omental  and  infraomental  space,  the  supraomental 
space  being  divided  into  the  subphrenic  and  sub- 
hepatic; the  diaphragmatic  area  being  again  divided 
by  the  hepatic  ligament  into  right  and  left  spaces. 
The  region  below  the  omentum  is  further  subdivided 
by  the  mesentery  of  the  ileum.  The  pelvic  cavity 
forms  the  lower  portion  of  this  region. 

When  the  appendix  lies  behind  the  ileocecal  junc- 
tion or  lateral  to  the  cecum  and  ascending  colon,  the  natural  tendency  of  the  pus 
is  to  collect  in  the  iliac  fossa  and  to  gravitate  upward  as  the  patient  lies  recumbent. 
The  upward  course  is  facihtated  by  the  direction  of  the  lymph-stream.  When  the 
appendix  occupies  the  dependent  position  the  pus  tends  to  pour  into  the  pelvis. 
The  upward  extension  of  the  suppurative  process  may  result  in  a  perirenal,  a  sub- 
hepatic, or  a  subphrenic  abscess;  its  downward  extension  results  in  a  superior  or 
an  inferior  pelvic  abscess. 

1  Porter,  M.  F.:     "Pyopneumo-appendix  due  to  Obstruction  by  a  Fecal  Concretion,"  Jour. 
Am.  Med.  Assoc,  1906,  xlvii,  435. 


Fig.     744. — Acutely     Inflamed 
Appendix    Lined  Through- 
out WITH    Necrotic    Mate- 
rial. 
At  a  and  a'  are   abscess  foci 

and  at   a"  a  pinhole  perforation. 

The    mesentery    (c)  ia  edematous 

and  hyperemic. 


APPENDICITIS. 


521 


Retroperitoneal  appendical  abscess  usually  develops  when  the  appendix  is 
situated  behind  the  peritoneum,  but  may  occur  when  the  intraperitoneal  organ  is 
adherent  to  the  parietes.  The  arrangement  of  the  renal  and  hepatic  fascia  and 
ligaments  favors  the  upward  extension  of  the  retroperitoneal  iliac  abscess,  and  it  is 
also  prone  to  travel  down  along  the  psoas  muscle,  and  between  the  rectum  and  pelvic 
peritoneum.  The  abscess  may  be  thin-walled  and  distinctly  fluctuating,  or  it  may 
consist  of  a  small  necrotic  focus  in  the  center  of  a  dense  mass  of  inflammatory  prod- 
ucts, resembling  a  new-growth,  which  may  remain  for  months  and  may  even  be- 
come calcified. 


Fig.  745. 


-Abscess  Surrounding  the  Proximal  Portion  of  the  Appendix. 
BUT  IS  Perfectly  Free. 


The  Distal  Half  is  Congested, 


The  appendical  abscess  may  rupture  into  the  general  peritoneal  cavity,  into  any 
of  the  hollow  viscera,  or  through  the  abdominal  walls.  The  internal  or  external 
fistula  resulting  from  the  rupture  of  the  abscess  may  persist  indefinitely,  or  may 
close  spontaneously,  and  in  some  instances  is  followed  by  complete  cure.  Again, 
the  septic  process  becomes  arrested,  the  inflammatory  products  are  absorbed,  and 
finally  only  a  few  dense  fibrous  adhesions  remain. 

Spreading  or  generalized  'peritonitis  may  be  divided  into  acute  septic,  serofi- 
brinous, and  purulent.  Septic  peritonitis  is  characterized  by  a  diffuse  reddening 
lack-luster  appearance,  and  sometimes  hemorrhagic  condition  of  the  peritoneum, 
and  the  absence  of  any  exudate  except  a  little  bloody  serum  or  a  few  flakes  of  fibrin. 


522 


OPERATIONS   FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 


In  rare  instances  of  streptococcus  infection  the  peritoneum  is  covered  with  a  thick 
gelatinous  deposit.  In  a  serofibrinous  peritonitis  the  fluid  may  be  free  in  the  general 
cavity  or  it  may  be  partly  encysted. 

Purulent  peritonitis  may  be  uniformly  and  diffusely  distributed  or  it  may  become 
encapsulated  here  and  there  between  the  viscera — the  progressive  fibrino-purulent 
peritonitis  of  jMikulicz — the  disease  advancing  from  one  area  to  another  and  form- 
ing fresh  foci  of  infection  as  it  progresses,  each  focus  being  imperfectly  walled  off. 


liij.  710.    -Densi:  Adhesions  Resultixu  eiiom  ax  Ulu  I'Eiiiroxiri.s  of  Appendical  Origin. 


Secondary  abscesses  in  this  form  of  infection  may  develop  in  any  part  of  the  abdom- 
inal cavity  and  in  the  pelvis.  They  are  frequently  found  between  the  coils  of 
intestine,  in  the  right  renal,  hepatic,  and  subphrenic  regions,  and  may  extend  to  the 
pleura. 

Suh'phrenic  Abscess. — The  frequency  and  importance  of  this  dangerous  compli- 
cation is  not  sufficiently  recognized.  Elsberg,^  in  1901,  collected  and  analyzed 
seventy-three   cases.     He   gives   the  following  methods   of  development:    (1)   A 

^Elsberg:  "A  Contribution  to  the  Pathology,  Diagnosis  and  Treatment  of  Sul)phrenic 
Abscesses  after  Appendicitis,"  Ann.  of  Surg.,  1901,  xxxiv.  729. 


APPENDICITIS. 


523 


il 


localization  of  a  general  infection ;  (2)  a  localized  abscess-formation  occurring  as  a 
part  of  a  diffuse  purulent  peritonitis;  (3)  a  local  process  by  direct  extension  or 
through  the  lymph-channels,  from  the  appendix.  The  third  is  the  most  frecjuent 
form.  The  abscess  may  be  intraperitoneal  or  extraperitoneal.  The  intraperitoneal 
subphrenic  abscess  is  usually  a  direct  extension  from  a  purulent  focus  below. 

In  the  extraperitoneal  variety  the  infection  advances  upward  behind  the  perito- 
neum, either  by  way  of  the  lymphatics,  or  as  a  direct  extension  from  a  purulent 
focus  about  the  appendix.     The  abscess  is  usually  confined  to  the  right  side  of  the 
suspensory  ligament,  but,  may  extend   to   the  left  side.     It  may 
also  penetrate  the  diaphragm  and  infect  the  pleura. 

Portal  Infection,  Pylephlebitis,  and  Liver  Abscess. — The  con- 
nections existing  between  the  appendical  vessels  and  the  portal 
system  permit  a  direct  extension  of  the  infective  process  in  the 
appendix  to  the  vena  porta  and  liver.  This  may  be  due  to  the 
continuous  propagation  of  the  infective  process  along  the  vascular 
channels,  or  it  may  be  due  to  the  lodgment  of  septic  emboli  in 
the  liver.  There  may  be  a  single  large  abscess,  or  the  entire  organ 
may  be  riddled  with  minute  suppurative  foci.  Abscess  of  the  liver 
is  less  frequent  in  the  fulminating  than  in  the  subacute  forms  of 
appendicitis. 

Thrombosis  and  pidmotiary  embolism  are  rare  complications  of 
appendicitis,  but  occur  more  frequently  as  post-operative  sequelse. 

Chronic  Appendicitis  and  Residual  Conditions. — The  sub- 
sidence of  an  acute  inflammation  seldom  results  in  a  complete 
restitutio  ad  integrum.  A  subacute  or  a  chronic  inflammatory 
process,  or  a  latent  focus  of  infection,  prone  to  give  rise  to  more 
or  less  acute  exacerbations,  may  persist;  there  may  be  a  complete 
subsidence  of  all  inflammatory  reaction  and  the  infective  material 
may  be  absorbed  while  the  appendix  is  indurated,  distorted,  and 
adherent  to  neighboring  structures;  or,  it  may  appear  normal 
externally  while  the  lumen  is  stenosed  or  strictujed  at  one  or 
more  points.  When  the  lumen  is  preserved  beyond  the  strictured 
area,  a  cyst  of  the  appendix  having  clear  mucoserous  or  serous 
contents  develops.  Histologically,  round-cell  infiltration,  in- 
crease of  fibrous  tissue,  and  vascular  degenerations  are  almost  invariably  present. 

Diverticula  of  the  appendix  are  not  very  rare.  They  may  be  single  or  multiple 
and  consist  of  cystic  protrusions  of  the  mucous  and  submucous  layers  beneath  the 
peritoneum  or  between  the  layers  of  the  mesentery.  They  vary  from  a  few  milli- 
meters to  several  centimeters  in  size.  The  majority  occur  on  the  side  of  the  mesen- 
teric attachment.  An  unusual  case  described  by  I.  C.  Herb^  consisted  of  a  globular 
cyst,   23  centimeters  in  circumference,  attached  to  the  middle  of    the  appendix 


^ 


Fig.  747.—  Ap- 
pendix Show- 
ing Multi- 
ple Stric- 
tures; Two 
Fecal  Masses 
IN  THE  Distal 
Portion. 


1  Herb,  Isabella  C. 
1907,  xlix,  2135. 


"Diverticulum  of  the  Vermiform  Appendix,"  Jour.  Amer.  Med.  Assoc, 


524 


OPERATIOXS    FOR    DISEASES    OF   THE   VERMIFOR^NI    APPEXDIX. 


Fig.  748. — Chronic  Appendicitis. 

The  appendix,  which  was  partly  embedded  in  the  posterior  wall  of  the  colon,  is  doubled  up  into  a  hard  rounded 

nodule  enveloped  in  adhesions.     The  section  shows  a  fecal  concretion  in  its  lumen. 


f  IG.  749. — Obliterated  Appendix. 
At  a  the  appendix  is  reduced  to  a  thin  fibrous  cord. 


APPENDICITIS. 


525 


opposite  the  mesenteric  border.  The  condition  is  probably  the  result  of  an  ante- 
cedent inflammatory  process. 

Etiology. — The  causative  factors  which  may  enter  into  the  production  of  an 
attack  of  appendicitis  may  be  considered  under  three  headings:  Predisposing; 
exciting;  and  final,  or  essential. 

Predisposing  causes  may  be  local  or  general.  Among  the  most  important  are  the 
normal  anatomic  and  physiologic  conditions.  The  mechanical  conditions  in  the 
appendix  are  such  as  favor  the  stagnation  of  its  contents,  with  a  consequent  increase 
in  the  virulence  of  the  contained  micro-organisms,  while  the  presence  of  abundant 
lymph-follicles  affords  a  portal  of  entry  for  bacteria.  Klemm,^  as  the  result  of  care- 
ful study,  concludes  that  appendicitis  is  a  specific  disease  of  the  lymphatic  tissue, 
which  does  not  differ  from  similar  affections  of  other  lymphatic  organs.  Previous 
attacks,  with  the  resulting  strictures,  kinks,  twists,  and  adhesions,  are  an  important 
cause  of   subsequent  attacks.     Adhesions  of   the   normal   appendix  to  adjacent 


'■r      '^ 


Fig.  750. — Cystic  Appendix. 
The  undilated  proximal  end  of  the  appendix  is  pervious,  but  at  its  junction  with  the  cystic  portion  it  is  completely 
obliterated.     The  surface  of  the  cyst  is  injected  and  covered  with  adhesions. 

Structures,  such  as  the  pelvic  organs,  or  to  the  "site  of  a  previous  operation,  also 
create  a  locus  minoris  resistentice.  Edebohls^  ascribes  to  the  floating  right  kidney 
an  important  role  in  the  etiology  of  the  disease. 

Age. — Appendicitis  is  a  disease  of  early  life,  four-fifths  of  all  cases  occurring 
before  the  age  of  thirty,  and  more  than  half  before  twenty. 

Exciting  Causes. — Disorders  of  digestion  are  by  far  the  most  important  exciting 
causes  of  an  appendical  attack;  other  factors  producing  a  physiologic  congestion, 
such  as  exposure  to  cold,  a  severe  strain,  or  menstruation,  are  occasional  exciting 
causes  of  recurrent  appendical  attacks.  Trauma,  especially  indirect  injury,  is  a 
somewhat  frequent  cause  of  an  acute  attack  where  previous  disease  has  existed. 
It  has  not  been  proved  that  trauma  ever  causes  inflammation  in  a  previously  normal 
appendix. 

>  Klemm,  P.:  "Ueber  die  Erkrank.  des  Lympatischen  Gewebes  u.  ihr  Verhaltniss  z.  Appen- 
dicitis," Deutsche  Ztschr.  f.  Chir.,  Leipz.,  1906,  Ixxxvi,  427. 

2  Edebohls,  G.  M.:  "The  Relation  of  Movable  Right  Kidney  and  Appendicitis,"  Am.  Jour. 
Obst.,  1895,  165. 


526 


OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 


Fig.  751.— Pin  En- 
crusted WITH 
Calcareous  Ma- 
terial, Removed 
FROM  the  Per- 
forated Inflam- 
ed Appendix. 
(After  Mitchell.) 


Foreign  bodies  and  concretions ,  which  formerly  were  supposed  to  be  the  principal 
exciting  causes  of  appendicitis,  are  now  known  to  play  a  very  subsidiary  part,  and 
are  found  in  only  a  small  proportion  of  even  severe  cases. 
Among  the  foreign  bodies  that  have  been  found  are  pins,  shot, 
pieces  of  bone,  lead,  hairs,  bristles,  seeds,  and  enterozoa.  The 
commonest  and  most  dangerous  of  these  are  pins  and  other 
pointed  bodies,  which  readily  enter  the  small  appendical  orifice 
and  pass  into  the  canal  (MitchelP).  They  may  remain  in 
the  canal  for  months,  becoming  encrusted  with  calcareous 
deposit  and  acting  as  a  constant  irritant  to  the  appendical 
walls,  which  the  point  may  finally  penetrate.  Except  in 
appendices  of  the  fetal  type,  it  is  impossible  for  light  bodies 
such  as  cherry-stones  and  orange-seeds  to  pass  the  narrow 
orifice.  Small  seeds  are  commonly  found, 
but  only  form  part  of  the  normal  ingesta 
and  readily  pass  in  and  out.  The  enterozoa,  especially  the 
ascaris  lumbricoides  and  the  oxyuris,  occasionally  provoke  an 
acute  attack  of  appendicitis.  In  two  cases,  at  least,  Bilharzia 
disease  has  developed  primarily  in  the  appendix.^  Concretions 
are  present  in  a  considerable  proportion  of  perforative  and 
gangrenous  appendicitides.  They  play  an  entirely  passive 
role,  obstructing  the  lumen  and  causing  pressure  anemia  of 
the  tissues.     (See  Fig.  752.) 

Final  or  Determining  Causes. — Bacteriology. — Pathogenic 
micro-organisms  always  form  the  final  or  immediate  cause  of 
appendicitis.  The  normal  flora  of  the  appendix,  innocuous 
when  controlled  by  the  secretions  of  the  healthy  bowel,  become 
highly  pathogenic  under  certain  conditions.  Traumatism, 
acute  congestion,  the  production  of  a  vas  clos,  angulation,  or 
strictures,  produce  a  locus  minoris  resistentice,  favorable  to  the 
growth  of  bacteria  and  incapable  of  resisting  their  invasion. 
The  following  are  the  most  important  micro-organisms  found 
in  inflammation  of  the  appendix.  The  bacillus  coli  communis 
is  found  the  most  frequently,  and  in  the  majority  of  cases  is 
the  only  organism  present,  but  also  occurs  in  combination 
with  other  bacteria.  The  streptococcus  pyogenes  can  be 
isolated  only  in  a  minority  of  cases,  but  is  of  great  importance 
in  the  causation  of  the  disease,  as  it  is  especially  associated 
with  the  most  severe  infections.  Other  intestinal  flora 
more  rarely  found  in  appendical  inflammation  are  the  bacillus  pyocyaneus,  micro- 


Concr. 


Fig.  752. — Acute  Per- 
forating Ap- 
pendicitis IN  A 
Girl  Three  and 
One-half  Years 
Old. 

The  appendix,^ 

which  has  preserved 
the  fetal  type,  has  a 
wide  funnel-shaped 

orifice  (a).  The  large 
opening  in  the  acutely 
inflamed  distal  portion 
of  the  appendix  is 
choked  with  a  fecal 
concretion. 


^  Mitchell,  J.  F.:     "Foreign  Bodies  in  the  Appendix,"  Johns  Hopkins  Hosp.  Bull.,  1894,  35. 
^  Burfield,  J.,  and  Shaw,  E.  H.:     "A  Case  of  Bilharzia  Infection  of  the  Appendix,"  Lancet,, 
1906,  1,  368. 


APPENDICITIS.  527 

COCCUS  pyogenes,  bacillus  of  the  hog  cholera  group,  and  bacillus  aerogenes  capsulatus, 
Inflammation  may  also  be  produced  by  the  introduction  of  virulent  micro-organisms 
into  the  general  circulation  (Roger^),  propagated  from  an  infective  enteritis  (Reclus^) 
or  may  be  due  to  a  descending  infection  from  the  gall-bladder  (Dieulafoy^). 

Appendicitis  as  a  Local  Expression  of  a  General  Infection. — Animal  experimen- 
tation has  demonstrated  that  the  lymphoid  tissue  of  the  appendix  is  the  seat  of  pre- 
dilection for  the  localization  of  infective  organisms  derived  from  the  general  circu- 
lation (Adrian*).  The  clinical  evidence  also  is  convincing.  The  frequent  associa- 
tion of  appendicitis  and  tonsillitis,  and  of  both  with  acute  rheumatic  fever,  is  well 
known;  as  well  as  the  definite  increase  in  the  number  of  cases  of  appendicitis  occur- 
ring during  the  large  epidemics  of  influenza,  and  its  association  with  other  general 
infections;  viz.,  measles,  scarlatina,  varicella,  and  parotitis.  The  relation  of  appen- 
dicitis to  typhoid  fever  is  probably  one  of  direct  propagation  from  the  small  intestine, 
rather  than  a  blood  infection.  It  is  not  determined  whether  the  general  infection 
merely  acts  as  an  exciting  factor  by  preparing  a  suitable  soil  for  the  activities  of  the 
intestinal  bacteria,  or  whether  the  specific  micro-organism  is  the  direct  cause  of  the 
appendicitis.  The  influenza  bacillus  and  the  pneumococcus  have  been  demonstrated 
in  appendical  abscesses  in  a  few  instances,  but  more  observations  are  necessary 
to  determine  the  exact  relationship  existing  between  these  affections. 

Symptoms  and  Diagnosis. — For  clinical  purposes  appendicitis  may  be  con- 
veniently divided  into  acute,  relapsing,  and  chronic  appendicitis. 

Acute  appendicitis  may  have  a  sudden  acute  onset,  or  may  be  ushered  in  insid- 
iously with  slight  digestive  disturbances  for  a  few  days,  followed  by  indefinite  local 
symptoms  which  steadily  increase  in  severity.  The  important  symptoms  include 
pain,  localized  tenderness,  rigidity,  nausea  and  vomiting,  constitutional  disturbances, 
distention,  tumor,  and  ileus. 

Pain. — Pain  is  the  first  and  most  important  early  symptom,  and  is  soon  followed 

by  nausea  and  vomiting;  increased  pulse-rate  and  rise  in  temperature  are  usually 

present  early,  in  a  direct  ratio  to  the  severity  of  the  pathologic  lesion  in  the  appendix. 

The  initial  pain  may  from  the  first  be  locahzed  in  the  right  lower  abdomen,  but  is 

commonly  referred  to  some  other  region,  especially  the  umbihcal  or  epigastric;  or 

it  may  be  diffused  over  the  whole  abdomen.     It  is  usually  paroxysmal,  cohcky,  and 

radiating,  in  the  beginning,  but  after  a  few  hours  it  becomes  localized  in  the  right 

iUac  fossa,  and  is  then  usually  continuous.     Acute  exacerbations  are  brought  on  by 

any  movement,  especially  such  as  involves  the  psoas  muscle;  hence  the  patient  lies 

in  the  dorsal  position,  and  often  keeps  the  right  thigh  flexed.     The  pain  may  be 

confined  to  a  very  small  area  in  the  appendical  region,  or  may  radiate  down  into  the 

groin,  to  the  lumbar  region,  or  toward  the  median  line — sometimes  causing  marked 

retraction  of  the  testicle.     In  the  case  of  an  ascending,  retrocecal  appendix  the  pain 

^  Roger:  "Les  Maladies  Infectieuses." 

^  Reclus:  "Pathogenie  de  I'appendicite,"  Sem.  med.,  1897,  2.37. 
^  Dieulafoy:  Bull,  de  I'academ.  de  med.,  Paris,  1904. 

^Adrian:  "Die  Appendicitis  als  Folge  einer  allgemeinerkrankung  u.  s.  w.,"'  Mitt.  a.  d. 
Grenz.  des  Med.  u.  Chir.,  1901,  Bd.  vii,  407. 


528  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 

may  be  in  the  region  of  the  gall-bladder  or  the  right  kidney;  or,  if  the  appendix 
hangs  down  over  the  pelvic  brim,  the  pain  may  be  confined  to  the  hypogastric  or  to 
the  pelvic  region.     Bladder  and  rectal  tenesmus  are  common  symptoms. 

The  pain  lessens  in  intensity  after  a  few  hours,  and,  in  a  simple  case,  usually 
ceases  in  from  twenty-four  to  forty-eight  hours.  An  increase  in  the  local  infection 
is  usually  marked  by  the  continuance  and  increasing  intensity  of  the  pain.  A  sudden 
sharp  pain  after  a  temporary  subsidence  often  means  a  perforation  or  a  beginning 
general  infection.  On  the  other  hand,  a  sudden  lull  in  the  local  symptoms,  not 
accompanied  by  general  improvement,  is  ominous  of  a  ruptured  pus  sac,  of  gan- 
grene, or  of  toxemia.  If  the  pain  again  becomes  generalized,  spreading  peritonitis 
may  be  suspected.  Severe  pain,  or  an  increase  in  its  intensity  after  the  first  few 
hours,  usually  indicates  a  rapidly  advancing  infection. 

Tenderness. — Localized  tenderness  is  the  most  valuable  sign  of  early  appendi- 
citis. It  is  a  symptom,  however,  which  must  be  estimated  with  considerable  cau- 
tion, as  it  is  apt  to  be  exaggerated  by  neurotic  patients.  If,  however,  the  patient's 
attention  is  diverted  by  engaging  him  in  conversation,  or  by  simultaneously  placing 
the  other  hand  on  some  other  part  of  the  body,  the  amount  of  tenderness  usually 
can  be  determined  accurately.  Tenderness  is  a  particularly  valuable  sign,  as  it 
persists  after  spontaneous  pain  has  ceased  and  is  present  throughout  the  course 
of  the  disease.  The  point  of  maximum  tenderness  is  usually  directly  over  the 
base  of  the  appendix,  or  it  is  over  the  point  where  the  pathologic  process  is  most 
marked. 

Muscle  spasm  is  a  certain  sign  of  an  acute  inflammatory  process,  but  is  present 
only  during  the  early  stages.  The  most  active  spasm  is  found  when  there  is  begin- 
ning peritonitis. 

Rigidity. — Next  to  pain  and  tenderness,  rigidity  of  the  abdominal  muscle  is  the 
most  reliable  early  sign  of  acute  appendicitis.  At  the  outset  it  is  general,  but  soon 
after  the  localization  of  the  infection  it  becomes  Hmited  to  the  right  side.  While  a 
valuable  sign,  it  often  disappears  early  and  may  be  very  slight  or  entirely  wanting 
in  the  most  serious  conditions;  on  the  other  hand,  pronounced  rigidity  may  be  noted 
in  the  presence  of  a  very  mild  inflammatory  process.  In  diffuse  peritonitis  there  is 
general  rigidity,  the  abdomen  becoming  uniformly  distended,  tense,  and  motionless, 
or  retracted  and  hard.  In  rare  instances  the  abdomen  is  soft  and  natural  looking 
in  the  presence  of  a  severe  general  peritonitis. 

Fever. — Rise  of  temperature  is  a  variable  sign.  It  is  usually  elevated,  but  may 
be  almost  normal  throughout,  and  is  rarely  high.  With  steadily  increasing  local 
symptoms  during  the  first  twenty-four  hours  of  the  attack,  the  temperature  may  not 
exceed  98.6°  F.  Increasing  fever,  however,  is,  as  a  rule,  indicative  of  a  severe 
inflammation,  and  a  continuous  high  temperature  after  the  first  forty-eight  hours 
almost  always  points  to  suppuration.  Disturbance  of  the  normal  ratio  between 
temperature  and  pulse  is  always  a  grave  omen.  A  high  temperature,  with  a  full, 
rapid  pulse-rate,  is  a  better  prognostic  sign  than  a  low  temperature  with  a  small, 
rapid  pulse.     The  pulse  is  usually  accelerated.     If  a  pulse  which  has  been  but  little 


APPENDICITIS.  529 

accelerated  begins  to  go  up,  operation  is  urgently  indicated,  as  there  is  either  a 
beginning  local  extension  of  the  disease  or  a  general  infection. 

Tumor. — A  mass  in  the  right  iliac  fossa  may  be  the  result  of  adherent  intestine, 
a  rolled-up  omentum  attached  to  the  appendix,  an  inflammatory  exudate,  or  an 
abscess  focus.  A  mass  may  be  simulated  by  the  rigidly  contracted  muscles  over 
the  affected  area,  and,  on  the  other  hand,  the  rigid  wall  may  hide  a  tumor  mass 
beneath.  The  presence  of  a  tumor  in  the  appendix  region  is  an  indication  for  early 
operation  unless  the  general  condition  is  decidedly  improving  and  the  mass  is  dis- 
tinctly decreasing  in  size  and  tenderness.  Delay  is  dangerous  when  there  is  persis- 
tent temperature,  or  when  the  mass  is  apparently  stationary  in  size  or  enlarging. 
It  is  impossible  to  foretell  at  what  moment  the  abscess  may  rupture  into  the  general 
cavity  or  to  detect  the  insidious  development  of  secondary  foci  of  suppuration. 

Vomiting. — This  is  an  inconstant  early  symptom  of  acute  appendicitis.  There 
may  be  a  slight  attack  of  vomiting  at  the  onset  of  the  disease,  or  it  may  occur  two 
or  three  hours  later  and  be  repeated  once  or  twice.  It  is  never  continuous  in  favor- 
able cases,  and  usually  ceases  in  a  few  hours.  Persistent  and  uncontrollable 
vomiting  indicates  the  presence  of  general  peritonitis.  H ematemesis  has  been 
noted  in  a  few  cases.     It  always  indicates  a  severe  infection. 

Constipation  is  present  in  the  majority  of  cases  of  acute  appendicitis,  but  may 
sometimes  be  preceded  by  an  attack  of  diarrhea.  Rarely,  diarrhea  continues 
throughout  the  attack. 

Ileus. — Persistent  ileus  is  one  of  the  most  urgent  indications  for  immediate  opera- 
tion. An  ileus  appearing  at  the  very  outset  may  be  due  to  the  violence  of  the  attack 
and  may  quickly  subside,  but,  when  persistent,  it  is  a  sign  of  a  spreading  peritonitis 
with  intestinal  paralysis,  or  it  arises  from  an  obstruction  of  the  bowel  due  to  a  kink 
or  compression.  There  is  constant  vomiting,  which  finally  becomes  fecal;  complete 
obstipation,  after  the  lower  bowel  is  emptied;  the  abdomen  is  distended;  in  ob- 
structive cases  peristalsis  at  first  is  marked,  but  finally  ceases. 

Chills  are  usually  observed  at  the  onset  of  septicemia  and  may  occur  at  irregular 
intervals.  They  are  usually  accompanied  by  a  high  temperature,  which  may 
show  daily  remissions  or  intermissions.  Repeated  rigors  with  an  intermittent  or 
remittent  temperature,  and  sweats,  indicate  a  pyemic  process;  when  jaundice  is 
also  present  there  is  a  pylephlebitis  or  a  liver  abscess. 

Icterus  developing  in  the  course  of  an  appendicitis  may  indicate  a  profound 
toxemia,  or  may  be  due  to  obstruction  of  the  bile-ducts  by  adhesions,  or  to  an 
infective  hepatitis  or  pylephlebitis. 

Leukocytosis. — The  value  of  the  leukocyte  count  as  a  diagnostic  and  prognostic 
sign  is  subject  to  considerable  difference  of  opinion.  The  importance  of  leukocy- 
tosis in  any  case  can  be  estimated  only  after  careful  consideration  of  all  the  factors 
which  modify  the  blood  count,  and  depends  upon  the  stage  of  the  disease  at  which 
the  count  is  made.  Early  in  the  disease  a  steadily  increasing  leukocytosis  in  con- 
nection with  other  symptoms  of  appendicitis  is  an  indication  for  immediate  opera- 
tion ;  later  in  the  disease  a  persistently  high  leukocytosis  of  20,000  or  more  is  almost 
VOL.  II — 34 


530  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 

always  a  sign  of  suppuration.  But  there  may  be  a  high  leukocytosis  with  compara- 
tively slight  lesion;  a  low  leukocyte  count,  on  the  other  hand,  may  accompanj^ 
the  most  violent  infections,  and  is  found  in  cases  where  the  organism  is  unable  to 
offer  any  resistance  to  the  overwhelming  intoxication.  A  moderate  leukocytosis 
of  10,000  or  12,000  in  the  early  stages  has  little  practical  significance,  as  it  may  be 
referred  to  a  variety  of  conditions.  In  children  a  high  leukocyte  count  is  normal 
and  is  increased  by  digestion.  In  pregnancy  the  leukocytes  vary  from  7,000  to 
13,000.  An  extremely  high  leukocytosis  of  25,000  to  40,000  in  the  early  stages 
should  be  regarded  with  suspicion  and  a  thorough  examination  of  the  chest  should 
be  made.  Intestinal  obstruction  from  any  cause  is  often  accompanied  by  marked 
leukocytosis.  The  differential  count  may  be  of  importance,  especially  with  an 
apparent  lull  in  the  acute  symptoms  or  with  an  exacerbation.  A  diminution  or 
absence  of  eosinophiles  at  this  time  is  very  significant  of  a  rapid  extension  of  the 
local  infection.  A  relative  increase  in  the  eosinophiles,  on  the  other  hand,  is  com- 
mon in  children  suffering  from  intestinal  disturbances  caused  by  the  presence  of 
parasites. 

In  the  presence  of  the  cardinal  symptoms — namely,  sudden  acute  abdominal 
pain,  tenderness  over  or  near  McBurney's  point,  and  localized  muscle  rigidity — 
the  diagnosis  of  appendicitis  is  justified  in.  the  majority  of  cases;  with  nausea  and 
vomiting,  elevation,  of  temperature,  and  accelerated  pulse-rate,  the  diagnosis  is 
more  positive  and  the  presence  of  a  tumor  makes  it  certain.  Any  one  or  almost  all 
of  these  symptoms  may  be  absent  while  the  disease  is  rapidly  progressing;  and,  on 
the  other  hand,  an  apparently  typical  symptom-complex  may  be  found  to  be  due 
to  some  other  abdominal  or  thoracic  affection. 

Urinalysis. — Lannelongue^  calls  attention  to  the  greatly  increased  urotoxic 
coefficient  in  severe  cases  of  appendicitis,  and  regards  this  sign  as  of  value  from 
the  standpoint  of  the  prognosis.  The  early  appearance  of  indican  in  appendicitis 
is  sometimes  of  value  in  differentiating  this  affection  from  the  general  infections, 
where  it  appears  later. 

Chronic  apfendicitis  usually  manifests  itself  by  the  presence  of  abdominal 
pain,  generally  located  in  the  right  side  and  often  associated  with  digestive  dis- 
turbances, especially  constipation  and  flatulency.  The  somewhat  frequent  associa- 
tion of  mucous  colitis  with  chronic  appendicitis  and  the  relief  obtained  in  some  cases 
after  removal  of  the  appendix  suggest  the  existence  of  an  etiologic  relationship 
between  the  two  affections. 

Differential  Diagnosis. — The^  principal  conditions  which  may  be  confused 
with  appendicitis  are:  Diseases  of  the  right  kidney  and  ureter,  diseases  of  the 
gall-bladder  and  ducts,  omental  and  intestinal  adhesions,  new-growth,  tuberculosis 
or  ulcer  of  the  cecum,  tumor  or  inflammation  of  the  uterine  adnexa,  extrauterine 
pregnancy,  and  an  inflamed  Meckel's  diverticulum. 

In  women,  disease  of  the  pelvic  organs  is  frequently  confused  with  appendicitis. 

^  Lannelongue:  "Toxicite  urinaire  dans  I'appendicite,"  Bull,  de  I'acad.  de  m^d.  Paris, 
Ixxi,  Nos.  18-21. 


APPENDICITIS.  531 

A  careful  bimanual  examination,  with  the  patient  under  an  anesthetic  if  necessary, 
will  at  once  reveal  the  existence  of  a  pelvic  affection,  but  in  making  the  differential 
diagnosis  the  frequent  coexistence  of  the  two  affections  must  be  constantly  kept  in 
mind. 

A  floating  kidney  has  occasionally  been  mistaken  for  appendicitis  and  operation 
undertaken.  A  careful  consideration  of  the  constitutional  symptoms  and  an  examin- 
ation in  the  standing  (Noble)  as  well  as  in  the  dorsal  position  should  make  the 
diagnosis  of  floating  kidney  clear.  An  examination  under  anesthesia  will  be  of  ser- 
vice in  definitely  palpating  the  appendical  region;  but  under  these  conditions  the 
examiner  loses  the  assistance  afforded  by  the  sensations  of  the  patient  under  the  ex- 
amination. 

Stone  in  the  kidney  or  ureter  and  also  acute  'pyelitis  may  simulate  appendicitis  in 
both  the  local  and  constitutional  symptoms.  The  urinalysis  will  usually  indicate 
the  presence  of  an  affection  of  the  urinary  tract,  and  then  with  the  aid  of  the  a:-ray 
and  ureteral  catheterization  an  accurate  diagnosis  may  be  made. 

With  stone  in  the  gall-bladder  or  an  adherent  cholecystitis,  the  local  manifesta- 
tions are  situated  in  the  upper  quadrant  and  often  radiate  toward  the  scapular 
region,  but  inflammation  of  an  ascending  retrocecal  appendix  may  give  rise  to 
exactly  the  same  symptoms;  while,  on  the  other  hand,  a  large  empyema  of  the 
gall-bladder  may  form  a  tumor  in  the  iliac  fossa  associated  with  pain  and  tenderness 
in  this  region. 

Inflammation  of  a  Meckel's  diverticulum  can  be  differentiated  only  by  means  of 
abdominal  section.  Fortunately,  with  few  exceptions,  the  abdominal  and  pelvic 
affections  which  may  be  mistaken  for  appendicitis,  in  themselves  call  for  surgical 
treatment,  and  the  only  question  involved  is  the  form  of  incision  best  adapted  to  the 
condition. 

The  differential  diagnosis  between  typhoid  fever,  in  the  early  stages,  and  appen- 
dicitis often  involves  the  most  anxious  consideration,  as  an  unnecessary  operation 
on  a  typhoid  case  might  be  the  direct  cause  of  a  fatal  outcome.  Severe  right  iliac 
pain,  local  tenderness,  and  muscular  rigidity  are  not  uncommon  initial  symptoms 
of  typhoid  fever.  In  such  cases  the  chief  reliance  must  be  placed  upon  the  general 
appearance  of  the  patient,  the  character  of  the  temperature  curve,  the  pulse,  and 
frequent  leukocyte  counts.  (See  p.  530.)  The  patient  should  be  kept  under  con- 
stant observation  until  the  diagnosis  is  secured. 

Pneumonia,  particularly  in  children,  often  begins  with  acute  abdominal  symp- 
toms, very  suggestive  of  appendicitis,  before  there  are  any  clear  thoracic  symptoms. 
The  high  initial  temperature  in  pneumonia  and  the  rapid  breathing  should  put  one 
on  his  guard;  a  high  early  leukocytosis  also  speaks  for  pneumonia.  With  these 
symptoms  the  case  should  be  carefully  watched  for  the  development  of  thoracic 
signs. 


532  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 


OPERATION. 

Before  proceeding  to  consider  the  question  of  operation  it  seems  advisable  to 
say  a  few  words  regarding  the  treatment  of  the  patient  until  surgical  aid  can  be 
secured.  Cases  in  which  operation  is  not  deemed  advisable  for  some  important 
reason  may  be  treated  by  the  Ochsner  method  throughout  the  attack,  but  in  all 
other  cases  it  should  be  regarded  merely  as  "first  aid"  (Coffey^)  until  a  surgeon 
can  be  secured. 

The  medical  treatment  of  appendicitis  may  be  summed  up  in  one  word, 
rest — absolute  rest  for  the  body  in  general  and  for  the  alimentary  tract  in  particular. 
The  patient  should  be  put  to  bed  and  kept  quiet  in  the  dorsal  position.  No  food 
should  be  given,  but  thirst  should  be  satisfied  by  sips  of  hot  water  or  small  pieces  of 
ice.  Pain  may  be  relieved  by  applying  an  ice-bag  to  the  abdomen.  The  bowels 
may  be  kept  at  rest  by  the  use  of  opium  or  morphin,  which  should  be  given  only  in 
small  doses,  so  as  not  to  dull  the  senses  of  the  patient  and  so  obscure  the  progress 
of  the  disease.  A  half  grain  of  opium  or  an  eighth  grain  of  morphin  is  usually 
sufficient  to  quiet  the  violent  pain.  Laxatives  by  mouth  or  enemata  are  to  be 
avoided. 

Indications  for  Operation. — Operations  on  the  appendix  may  be  divided, 
according  to  the  time  at  which  they  are  performed,  into  two  main  groups;  those 
performed  during  the  attack,  and  interval  operations  {a  chaud  and  a  froid).  The 
former  group  may  be  subdivided  into  early,  intermediate,  and  late. 

Early  Operations. — An  ideal  operation  is  performed  within  the  first  few  hours 
of  the  onset  of  the  attack,  before  the  periappendical  structures  have  become  involved 
and  before  any  signs  of  a  general  toxemia  have  manifested  themselves.  Unless 
definite  contraindications  exist,  operation  should  be  undertaken  at  the  very  outset, 
without  waiting  for  the  development  of  symptoms  showing  whether  the  attack  is  going 
to  be  a  mild  or  a  severe  one.  Early  operation  is  especially  urgent  in  children,  as  they 
are  more  subject  to  the  severe  forms  of  appendicitis  than  are  adults.  It  is  impossible 
to  tell  in  a  given  case  how  rapidly  the  disease  is  progressing;  in  some  cases  slight, 
indefinite  symptoms  continue  for  some  days  before  the  disease  culminates  in  a 
severe  attack;  in  other  cases  perforation  is  present  at  the  onset  of  clinical  signs. 
The  physician  should  not  wait  for  the  development  of  pronounced  symptoms 
before  sending  for  a  surgeon,  but  should  make  use  of  the  other's  greater  experience 
in  diagnosing  surgical  affections.  Coffey^  states  that  in  one-half  of  the  cases  referred 
to  him  by  other  physicians  the  diagnosis  has  not  been  made  before  the  end  of  the 
third  day  with  any  degree  of  positiveness.  Almost  all  the  deaths  in  the  hands  of 
well-trained  abdominal  surgeons  are  the  result  of  (1)  failure  of  the  family  physician 
to  recognize  the  disease  early,  (2)  temporizing  with  medication  or  with  the  Ochsner 
treatment,  (3)  the  inability  to  procure  a  competent  surgeon  early,  (4)  the  opposition 

1  Coffey,  R.  C:     "The  Present  Status  of  the  Treatment  of  Appendicitis,"  N.  Y.  Med.  Jour., 
1906,  Ixxxiv,  325. 
^  Coffey:  Loc.  cit. 


OPERATION.  533 

of  members  of  the  family  to  surgical  intervention.  Early  operation  has  the  follow- 
ing advantages:  increased  safety,  as  serious  complications  are  avoided;  the  opera- 
tion is  more  easily  performed,  as  recent  adhesions  and  periappendical  exudate 
are  not  found;  the  patient  is  spared  a  severe  illness;  the  use  of  drainage  is  avoided, 
and  consequently  the  risk  of  later  hernia;  one  operation  cures  the  patient,  whereas 
after  late  operations  it  is  frequently  necessary  to  perform  a  second  operation  for 
either  hernia  or  for  intestinal  adhesions. 

Intermediate  Operation. — When  the  patient  is  not  seen  until  the  disease  is 
well  advanced,  one  of  the  most  difficult  problems  that  occurs  in  surgical  practice  is 
encountered.  At  this  time  the  risk  of  breaking  up  adhesions  and  of  distributing 
a  partially  localized,  active  infection  is  such  that  many  surgeons  prefer  to  wait 
until  a  later  period,  in  the  hope  that  the  disease  will  abate  or  that  a  suppurative 
process  will  be  well  walled  off  and  can  be  opened  with  safety.  They  believe  that 
the  risk  of  perforation  is  less  than  the  risk  of  operating  at  this  period.  Obstipation 
and  great  distention  of  the  abdomen  with  gas  are  conditions  especially  unfavorable 
for  operation.  Others  believe  that  in  competent  hands  the  danger  of  spreading 
the  septic  material  need  not  be  feared,  and  that  operation  should  be  performed 
whenever  the  diagnosis  is  established.  Dehnite  contraindications  to  delay  are,  if 
the  disease  is  getting  worse,  or  if  it  is  not  definitely  improving.  The  only  case  in 
which  delay  is  permissible  is  when  the  patient  who  is  seen  for  the  first  time  by  the 
surgeon  is  manifestly  recovering  from  a  mild  attack. 

A  late  operation  is  performed  after  the  development  of  a  well-defined  abscess, 
for  progressive  peritonitis,  or  for  other  serious  complications  which  occur  late  in  the 
attack.  It  is  never  the  operation  of  choice,  but  is  one  of  necessity  in  some  cases 
where,  through  the  fault  of  the  patient,  the  physician,  or  the  surgeon,  or  because  of 
some  unavoidable  circumstance,  an  early  operation  could  not  be  performed.  If 
the  patient  is  apparently  in  extremis  when  first  seen,  there  is  sometimes  a  question 
regarding  the  duty  of  the  surgeon,  but  the  occasional  recovery  of  apparently  hope- 
less cases  plainly  indicates  the  course  to  be  pursued. 

Interval  Operations. — An  interval  operation  is  one  which  is  undertaken  after 
the  complete  subsidence  of  an  attack,  whether  the  first  or  after  repeated  attacks, 
and  while  the  patient  is  enjoying  perfect  health,  for  the  purpose  of  obviating  any 
possibihty  of  recurrent  attacks.  The  chief  indications  for  an  interval  operation 
are:  the  recurrence  of  attacks  at  short  intervals;  a  single  attack  in  children,  or  in 
women  who  may  become  pregnant;  chronic  pain  or  digestive  disturbances  due 
to  adhesions;  and  the  fact  that  a  patient  who  has  had  an  attack  of  appendicitis  is 
remote  from  surgical  aid. 

Preparation  for  Operation. — When  an  early  operation  is  determined  upon  in 
a  case  of  acute  appendicitis,  the  preparation  should  be  made  as  quickly  as  possible, 
and  no  consideration  of  convenience  or  sentiment  should  be  permitted  to  interfere 
with  its  immediate  performance.  Even  a  few  hours  may  be  of  vital  moment  at 
this  time.  In  the  course  of  the  preparation  the  patient  should  be  disturbed  as  little 
as  possible.     All  food  should  be  withheld  and  no  attempt  should  be  made  to  have 


534  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 

the  bowels  moved,  as  even  a  small  enema  may  excite  continuous  peristalsis.  A 
hypodermic  of  morphin,  ^  or  ^  of  a  grain,  while  the  preparations  are  being  made, 
is  of  value  in  relieving  the  suffering  and  quieting  the  nervousness  of  the  patient. 

Preparation  of  the  Abdomen. — The  skin  of  the  right  half  of  the  abdomen  should 
be  shaved  and  the  entire  abdomen  then  cleansed  by  scrubbing  well  with  hot  water 
and  green  soap,  applied  with  sterile  gauze  sponges.  A  little  ether  followed  by  alco- 
hol should  then  be  used,  and  finally  the  whole  abdomen  sterilized  with  1  :  1000 
solution  of  bichlorid  of  mercury.  If  the  abdomen  has  been  blistered,  the  skin  should 
be  prepared  with  especial  care,  as  if  there  are  small  areas  of  suppuration  they 
may  result  in  an  infection  of  the  wound  or  even  of  the  peritoneal  cavity.  It  would 
be  well  in  such  a  case  to  sponge  the  field  of  operation  with  potassium  permanganate, 
followed  by  oxalic  acid,  before  using  the  bichlorid  solution,  and  the  area  about  the 
incision  may  then  be  protected  with  rubber  tissue.  Care  must  be  exercised  not  to 
rub  the  abdomen  too  vigorously  if  an  abscess  is  suspected,  as  it  may  be  ruptured. 

Incision. — The  best  location  for  the  incision  in  a  given  case  depends  upon  its 
adaptation  to  the  condition  present.  In  a  case  of  simple,  uncomplicated  appendi- 
citis, an  incision  in  the  right  ihac  region,  directly  over  McBurney's  point,  is  the 
most  convenient,  but  if  a  mass  is  present  the  incision  should  usually  be  made  directly 
over  the  most  prominent  point,  or  external  to  it,  parallel  to  Poupart's  ligament  or 
the  iliac  crest. 

The  principal  incisions  employed  are:  (1)  The  obhque,  or  McBurney,  or  grid- 
iron;   (2)  the  lateral,  vertical,  or  semilunar;   and  (3)  the  median. 

The  gridiron  or  McBurney  incision  is  the  ideal  one  in  all  cases  when  an  abscess 
requiring  drainage  is  not  present.  If,  however,  an  unsuspected  abscess  is  found 
upon  opening  the  abdomen,  the  incision  can  readily  be  extended  downward  by 
cutting  directly  through  all  the  layers,  and  this  affords  an  excellent  opportunity 
for  drainage.  The  advantages  of  the  McBurney  incision  are:  Its  location,  affording 
ready  access  to  the  appendix;  and  its  freedom  from  danger  of  subsequent  hernia. 
Since  the  muscle  fibers  are  merely  separated,  there  is  practically  no  bleeding,  and 
no  nerves  are  divided. 

The  semilunar  incision,  performed  according  to  Battle's  method,  is  especially 
useful  when  there  is  a  suspicion  of  an  involvement  of  other  abdominal  or  the  pelvic 
organs,  as  it  affords  an  excellent  opportunity  to  inspect  these  structures,  and,  if 
necessary,  to  operate  upon  them.     Many  surgeons  prefer  this  incision  for  all  cases. 

A  median  incision  is  never  employed  for  an  uncomplicated  appendicitis,  but  may 
be  utilized  with  advantage  for  the  inspection  of  the  appendix,  and  its  removal,  where 
disease  of  the  appendix  complicates  the  pelvic  affection  for  which  the  operation  is 
primarily  performed.  Its  disadvantages  are  that  the  incision  has  to  be  a  long  one, 
as  it  is  impossible  to  reach  the  base  of  the  appendix  through  a  short  median  incision. 
If  the  appendix  occupies  the  ascending  retrocecal  position  and  is  adherent,  the  dif- 
ficulties of  its  removal  through  a  median  incision  are  so  great,  except  in  the  case  of 
great  relaxation  of  the  abdominal  walls  and  the  very  long  incision  following  the 
removal  of  a  large  tumor,  that  we  consider  it  advisable  to  make  a  second  small  inci- 


OPERATION.  535 

sion  in  the  right  ihac  region  rather  than  to  unduly  prolong  the  original  incision  in 
order  to  be  able  to  retract  it  far  enough  over  to  the  right  side  to  reach  the  appendix 
with  ease.     (For  a  further  consideration  of  the  incision  see  Vol.  I,  Chapter  XII.) 

Removal  of  the  Appendix. — After  opening  the  abdomen  the  appendical  region 
should  be  explored  with  the  greatest  care  as  so  to  avoid  opening  into  a  purulent 
focus,  or  rupturing  a  tensely  distended  or  necrotic  appendix.  The  intestinal  or 
omental  adhesions  may  be  encountered  immediately,  and  should  be  carefully  sepa- 
rated as  far  as  possible.  The  tip  of  the  appendix  may  be  visible  at  once,  but  if  it 
does  not  come  into  view,  one  or  two  fingers  may  be  introduced  and  the  cecal  region 
gently  explored.  The  search  may  be  facilitated  by  first  locating  the  cecum  and 
then  following  down  the  anterior  longitudinal  band  to  the  base  of  the  appendix, 
when  it  may  be  easily  traced  in  whatever  direction  it  may  lie.  The  appendix  may 
be  completely  concealed  behind  the  cecum,  and  must  then  be  sought  for  by  loosening 
up  the  cecum  until  the  organ  is  brought  into  view,  either  lying  free  in  a  peritoneal 
pocket  or  plastered  to  the  posterior  surface  of  the  cecum  or  the  abdominal  wall. 

If  the  appendix  appears  to  be  fairly  normal,  a  thorough  exploration  should  be 
made  before  removing  it  for  the  purpose  of  finding  out  the  cause  of  the  clinical 
symptoms.  The  important  conditions  to  keep  in  mind  are:  kidney  and  ureteral 
disease,  affections  of  the  biliary  apparatus,  omental  and  intestinal  adhesions,  new- 
growth  or  tuberculosis  of  the  cecum,  diverticulitis,  and  pelvic  disease. 

Whenever  the  abdomen  is  opened  for  appendicitis  the  appendix  shauld  be  re- 
moved, whether  it  appears  to  be  diseased  or  not. 

Typical  Operation  for  Removal  of  the  Apperidix. — The  two  important  steps  in 
removal  of  the  appendix  are  the  ligating  of  its  mesentery  and  the  treatment  of  the 
stump. 

Ligation  of  the  Mesentery. — With  a  well-developed  mesentery  the  vessels  can 
usually  be  controlled  by  means  of  a  single  ligature  applied  to  the  main  vessel  at 
the  free  border  of  the  mesentery  near  the  base  of  the  appendix.  As  in  about  62 
per  cent,  of  the  cases  the  head  of  the  cecum  is  supplied  by  a  branch  from  this  vessel, 
it  is  safer  not  to  tie  it  too  far  out,  so  as  to  include  the  cecal  branch.  On  the  other 
hand,  in  a  small  number  of  cases,  about  5  per  cent.,  the  cecal  artery  supplies  the 
proximal  portion  of  the  appendix,  and  precautions  must  be  taken  against  hemor- 
rhage from  this  source,  an  accident  which,  however,  is  probably  avoided  by  the 
method  of  crushing  and  cauterizing  the  stump  so  generally  used  at  present.  If  the 
mesentery  is  short,  it  is  difficult  to  expose  the  main  vessels  above,  and  it  is  then 
necessary  to  tie  the  vessels  singly.  After  tying  the  vessels  they  may  be  clamped  on 
the  appendical  side  of  the  ligature  and  the  mesentery  divided  between.  The  appen- 
dix should  then  be  isolated  by  means  of  gauze  strips  carefully  placed  about  its  base 
to  prevent  any  possibility  of  contamination  when  it  is  resected. 

Treatment  of  the  Stump. — The  present  methods  of  dealing  with  the  stump  in- 
clude the  early  crude  simple  ligation  and  excision,  turning  back  a  peritoneal  cuff 
to  cover  the  ligated  stump  after  sterilization,  inversion  and  suturing,  and  amputa- 
tion close  to  the  cecum  and  suturing.     The  following  method  is  the  most  satis- 


536 


OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 


factory:  After  ligating  and  dividing  the  mesappendix  a  circular  suture  of  fine  silk 
or  Pagenstecher  (other  surgeons  prefer  chromicized  catgut)  is  placed  in  the  cecum 
near  the  base  of  the  appendix.  It  is  advisable  to  pass  the  suture  under  the  mesen- 
tery, as  when  it  is  tied  it  controls  any  bleeding  at  this  point.  The  suture  shov^n 
in  Fig.  753  is  even  more  satisfactory  than  the  simple  circular  suture.  Three  clamps 
are  then  applied,  as  shown  in  Fig.  753,  at  the  base  of  the  appendix;  the  one  at  the 


Fig.  753. — Halsted's  Three  Clamp  Method  of  Removal.     First  Step. 
The  circular  suture  is  placed  as  shown;    the  clamps  are  then  applied,  the  lower  one  first. 


base  being  first  applied,  followed  by  the  middle,  and  the  distal  one  last.  In  place 
of  the  ordinary  hemostatic  clamp,  a  heavy  crushing  clamp,  such  as  the  one  devised 
by  Kelly  or  that  of  Ferguson,  may  be  used  with  advantage.  The  middle  clamp 
is  then  removed,  and  the  appendix  is  amputated  at  this  point  with  the  Paquelin 
cautery.  If  the  cautery  is  not  convenient,  a  knife  may  be  used  and  the  stump 
may  be  cauterized  with  carbolic  acid.  When  the  clamp  at  the  base  is  removed, 
the  ribbon-like  band  which  completely  seals  the  stump  is  seized  with  delicate  forceps 


OPERATION. 


537 


by  an  assistant,  and  carefully  invaginated  into  the  cecum;  the  circular  suture  is 
then  drawn  taut  and  tied.  A  row  of  mattress  sutures  or  a  continuous  Lembert 
suture,  bringing  the  serous  surfaces  together,  may  then  be  placed  over  this  for 
greater  security. 

Adhesions. — In  the  case  of  adhesions  complicating  appendicitis,  particular  care 
must  be  taken  to  avoid  injury  to  the  bowel.  In  the  simplest  cases  the  delicate  web- 
like adhesions  are  readily  separated  with  the  finger,  and,  as  a  rule,  ligatures  are  not 
necessary.  If  dense  adhesions  are  present,  they  should  be  carefully  divided,  under 
the  guidance  of  the  eye,  with  scissors,  and  the  bleeding  points  tied  with  catgut 
ligatures.  It  is  not  uncommon  to  find  a  tag  of  omentum  firmly  attached  to  the 
appendix,  or  even  to  find  the  entire  ap- 
pendix rolled  up  in  a  mass  of  omentum. 
This  complication  is  easily  dealt  with 
by  removing  the  adherent  portion  of 
omentum  with  the  appendix,  first  tying 
off  the  proximal  portion  of  the  omentum 
with  fine  catgut,  and  dividing  it  with 
scissors. 


Removal  of  a  Retroperitoneal  or  a 
Densely  Adherent  Appendix. — In  certain 
instances  where  the  removal  of  the  ap- 
pendix is  unusually  difficult  the  operation 
may  be  facilitated  by  first  freeing  the 
appendix  from  the  cecum  in  the  usual 
manner,  then  making  a  longitudinal  in- 
cision over  the  appendix  down  to  the 
submucosa  or  internal  muscular  coat,  and 
finally  stripping  the  appendix  out  of  its 
bed  by  grasping  the  proximal  end  and 
using  gentle  traction.     (See  Fig.  759.) 

Treatment  of  Appendical  Abscess. — 
The  important  question  in  dealing  with 

a  periappendical  abscess  relates  to  the  treatment  of  the  appendix.  In  most  cases 
the  best  plan  is  to  make  a  simple  incision,  evacuate  the  abscess,  and  freely  drain  it, 
paying  no  attention  to  the  appendix.  In  some  cases  the  necrotic  appendix  will 
float  out  with  the  discharge;  in  many  cases  it  becomes  completely  obUterated  and 
gives  no  further  trouble;  in  other  cases  a  secondary  operation  is  required  for  its 
removal.  This  is  easily  and  safely  performed  after  the  patient  has  been  restored 
to  health,  and  the  infective  process  has  subsided,  leaving  merely  more  or  less  dense 
fibrous  adhesions.  Israel  estimates  that  recurrent  attacks  take  place  in  about  50 
per  cent,  of  the  cases  of  simple  appendicitis,  but  in  only  5  per  cent,  of  the  sup- 


FiG.  754. — Halsted's  Three  Clamp  Method. 
Second  Step. 
Tlie  middle  clamp  is  removed,  the  appendix 
burned  through  with  the  cautery  between  the  re- 
maining clamps,  and  the  stump  inverted.  If  a  knife 
is  used  in  place  of  the  cautery,  care  should  be  taken  to 
sterilize  the  stump  with  carbolic  acid. 


'  Israel,   J.:     "Diskussion  liber  Appendicitis,"  Verhandl. 
Woch.,  1906,  xliii,  1081. 


irztlich.    Gesellschft.   Berl.   klin, 


538 


OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 


purative  cases  and,  if  the  patient  is  free  from  recurrence  for  two  years  after  the 
attack,  the  appendix  is  probably  obliterated  and  no  further  danger  need  be  feared. 
The  secondary  operation  for  the  removal  of  the  appendix  should  be  performed 
if  there  is  chronic  pain,  if  repeated  attacks  occur,  in  the  case  of  children  and  in  the 
case  of  pregnant  women  or  w^omen  w^ho  expect  to  become  pregnant.  If  the  patient 
is  nervous  about  the  possibility  of  relapse,  or  if  he  is  remote  from  surgical  aid, 
operation  is  advisable.     Jaffe,'  out  of  one  hundred  cases  which  were  opened  and 


Fig.  755. — H.  A.  Kelly's  Method. 
The  mesappendix  is  ligated  and  divided.     A  circular  suture  or  mattress  sutures  are  then  placed  ready  to  turn 
in  the  stump.     The  appendix  is  then  crushed  near  its  base  with  powerful  grooved  forceps  and  held  away  from  the 
cecum  by  wet  gauze.     It  is  then  slowly  amputated  with  the  cautery. 

drained,  saw  only  five  in  which  it  was  necessary  to  remove  the  appendix  at  a  later 
date;  while  Barling,"  in  forty-nine  abscess  cases  in  which  the  appendix  was  not 
removed,  saw^  only  one  recurrence.  -  The  incision  should  be  made  over  the  loca- 
tion of  the  pus  and  rather  to  the  outside,  near  Poupart's  hgament,  or  the  crest 
of  the  ileum,  and  should  be  in  the  direction  of  the  fibers  of  the  external  oblique. 
It  is  a  good  plan  to  pull  the  muscles  open,  and  to  open  the  abscess  by  blunt  dissec- 
tion.    It  is  very  essential  to  have  an  opening  large  enough  to  allow  for  drainage, 

1  Jaffe:     "Wann  soil  bei  Perityphlitis  operirt  werden,"  Berl.  klin.  Woch.  xl,  1903,  1184. 

2  Barling,  Gilbert:     "  Pelvic  Appendicitis  with  Parappendical  Abscess  and  Cystitis,"  Lancet, 
London,  1907,  i,  1345. 


OPERATION. 


539 


and,  if  necessary,  the  incision  may  be  enlarged  by  cutting  through  the  whole  thick- 
ness of  the  abdominal  walls  in  either  an  upward  or  a  downward  direction,  as  seems 
best.  If  the  appendix  comes  into  view,  it  may  be  clamped  and  removed  in  the  usual 
way,  but,  as  a  rule,  it  is  better  to  leave  it;  or  it  may  be  simply  tied  off  and  the  stump 
disinfected. 

The  Cleansing  of  the  Abscess  Cavity. — A  wide  opening  for  drainage  and  thorough 
evacuation  are  usually  all  that  is  necessary,  and  further  manipulation  is  apt  to  do 
more  harm  than  good.  The  cavity  should,  however,  be  carefully  explored  to  ascer- 
tain that  there  are  no  other  cavities  communicating  with  it,  or  even  distinct  from  it. 
If  any  such  are  found,  they  must  be  opened  and  drained.  A  cigarette  drain 
may  be  placed  so  as  to 
reach  the  lowest  part  of 
the  abscess,  and  the  re- 
mainder of  it  should  be 
liffhtlv  filled  with  iodo- 
form  gauze. 

Special  Forms  of  Ab- 
scess:— In  some  cases  the 
abscess  is  inaccessible 
without  opening  the 
general  peritoneal  cavity. 
A  small  periappendical 
abscess  may  be  located  in 
the  midst  of  the  roUed-up 
omentum,  or  may  sur- 
round the  base  of  the 
appendix,  or,  again,  even 
a  large  abscess  may  form 
between  the  folds  of  the 
mesentery.  The  best  way 
to  approach  the  abscess 
in  such  cases  is  by  means 

of  the  semilunar  incision,  carefully  isolating  the  purulent  focus,  protecting  the 
surrounding  healthy  peritoneum  with  sterile  gauze,  and  then  evacuating  the  abscess 
transperitoneally. 

In  about  one-third  of  the  cases  of  suppurative  periappendicitis  the  pus  gravitates 
into  the  pelvis;  in  about  one-half  of  this  third  the  pus  is  confined  to  the  pelvis,  and 
may  be  entirely  concealed  in  the  true  pelvis.  In  others  the  pelvic  abscess  is  associated 
with  an  iliac  abscess,  which  may  have  a  direct  avenue  of  communication  with  the 
pelvic  abscess  or  may  be  distinct  from  it.  In  the  majority  of  such  cases  the 
appendix  itself  is  located  in  the  pelvis  (periappendical  abscess),  but  in  a  considerable 
number  the  appendix  is  situated  above  the  pelvic  brim  and  has  no  apparent  commun- 
ication with  the  abscess. 


Fig.   756. — The   Stump   is   Invaginated   into  the   Cecum. 


540 


OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 


Fig.  757. — Runyon's  Suture. 
The  suture  is  introduced  at  point  a,  carried  around  to  point  b, 
then  started  again  at  c  and  carried  to  d;   the  two  ends  at  a  and  d 
are  then  tied. 


In  all  cases  of  large  abscess  filling  the  pelvis,  the  rectal  incision  for  evacuation 

and  drainage  can  be  satisfac- 
torily employed,  especially  in 
men  and  in  children.  In  women 
the  abscess  can  be  drained 
through  the  vagina  when  the 
mass  is  discovered  in  the  poste- 
rior cul-de-sac.  The  cervix  uteri 
should  be  draw^n  forward  with 
a  tenaculum  forceps,  and  the 
posterior  vaginal  wall  retracted, 
when  a  wide  transverse  incision 
is  made  just  behind  the  cervix 
directly  into  the  abscess.  If  the 
abscess  is  discovered  after  the 
abdomen  is  opened,  the  question 
arises  whether  to  open  it  trans- 
peritoneally  or  to  close  the  in- 
cision and  drain  from  below. 
The  latter  we  believe  to  be  the 
most  satisfactory  procedure,  if 
the  abscess  occupies  the  true 
pelvis,  as  it  avoids  the  risk  attending  the  separation  of  the  matted  intestines  above, 
and  the  difficulty  of  securing 
satisfactory  drainage  of  the 
deepest  part  of  the  abscess  by 
the  abdominal  route.  When 
the  abscess  cannot  be  readily 
reached  from  below,  the  trans- 
peritoneal route  is  the  best, 
the  normal  intestine,  the  peri- 
toneum, and  the  edges  of  the 
incision  being  carefully  pro- 
tected by  means  of  gauze 
packs,  before  opening  the  ab- 
scess. 

Treatment  of  Subphrenic 
Abscess  and  of  Liver  Abscess. — 
As  soon  as  the  diagnosis  is 
made  the  only  course  to  pursue 
in   any   case   is   to   open   and 

drain  the  abscess.     A  large  solitary  liver  abscess  offers  some  slight  hope  of  a  cure, 
but    disseminated  abscesses    are    beyond  surgical  aid.     The  subphrenic   abscess, 


Fig.  758. — The   Operation   Completed. 


OPERATION. 


541 


according  to  Elsberg,^  may  be  best  reached  as  follows:  About  two  inches  of  the 
ninth  and  tenth  ribs  are  resected,  somewhere  between  the  scapular  and  the  anterior 
axillary  lines,  according  as  the  exploring  needle  has  located  the  pus  more  anteriorly 
or  more  posteriorly.  After  the  ribs  have  been  resected,  the  diaphragm,  with  the 
liver  shining  below  it,  will  appear  in  the  inferior  portion  of  the  wound,  and  the 
pleura  in  the  upper  part.  If  there  is  a  suspicion  that  the  pleural  cavity  contains 
pus,  it  should  be  aspirated,  and,  if  necessary,  opened  and  drained  at  once.  If  there 
is  no  pus  in  the  pleura,  the  upper  part  of  the  wound  should  be  protected  with  gauze, 
and  the  aspirating  needle  should  then  be  made  to  perforate  the  diaphragm  below 
the  pleural  reflection;  if  the  needle  enters  the  abscess  it  may  be  used  as  a 
director.  A  small  incision  of  the  diaphragm  beside  the  needle,  dilatation  of  the 
opening  with  dressing  forceps,  and  drainage  of  the  abscess  complete  the  operation. 
The  abscess  may  be  situ- 
ated so  near  the  median 
line,  high  up  under  the 
dome  of  the  diaphragm, 
that  it  can  be  reached  only 
by  the  transpleural  route. 
The  pleural  cavity  must 
then  be  opened  through  the 
upper  part  of  the  wound. 
If,  however,  pleural  adhe- 
sions have  formed,  it  may 
be  possible  to  avoid  open- 
ing into  its  cavity. 

Treatment  of  Appendic- 
itis Complicated  by  Diffuse 
or  Generalized  Peritonitis. 
— In  every  case  of  spread- 
ing or  generalized  peritonitis  the  rule  should  be  to  operate  as  soon  as  the 
diagnosis  is  made.  Many  cases  of  acute  septic  or  streptococcic  peritonitis 
terminate  fatally  within  the  first  twelve  or  eighteen  hours  after  the  appearance  of  the 
earliest  symptoms,  and  unless  operation  is  performed  early,  the  disease  is  practically 
always  fatal.  Diffuse  or  generalized  peritonitis  does  not  always,  however,  indicate 
a  virulent  infection,  and  when  the  organism  is  not  overwhelmed  by  the  onslaught 
of  highly  virulent  micro-organisms  or  the  excessive  amount  of  less  severely  patho- 
genic organisms,  an  immediate  protective  reaction  takes  place,  and  an  abundant 
purulent  or  fibrino-purulent  exudate  is  poured  out  which  diminishes  and  dilutes 
the  bacterial  toxins  and  destroys  the  bacteria.  Such  cases  are  relatively  favorable 
and  recovery  frequently  follows  operative  intervention.      According  to  Wathen,^ 

^  Elsberg:    Loc.  cit. 

'Wathen:     "Acute   Suppurative   Peritonitis,"    Jour.   Amer.    Med.    Assoc,   Chicago,    1907, 
xlviii,  1919. 


Fig.  759. — Showing  the  Method  of  Stripping  Out  the  Mucosa  and 

SUBMUCOSA  IN  THE   CaSE  OF  A  DENSELY  ADHERENT  APPENDIX. 


542  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM    APPENDIX. 

it  is  not  advisable  to  administer  opium  either  before  or  after  operation  for  periton- 
itis on  account  of  the  tendency  of  this  drug  to  diminish  leukocytosis.  On  the 
other  hand,  the  administration  of  normal  salt  solution  per  rectum  after  the  method 
of  Murphy,  or  of  hot  horse  serum,  or  saline  solution  in  the  peritoneal  cavity  or 
subcutaneously,  is  advocated  in  order  to  stimulate  leukocytosis.  The  operation 
should  be  performed  rapidly;  if  possible,  the  focus  of  infection  should  be  removed 
by  exsecting  the  appendix,  avoiding  exposure  or  handling  of  the  intestine  as  far  as 
possible.  Isolated  foci  of  infection  should  be  opened,  but  no  attempt  should  be  made 
to  sponge  off  the  intestines  nor  to  separate  adhesions.  Some  surgeons  are  strongly 
in  favor  of  flushing  out  the  peritoneal  cavity  with  large  quantities  of  saline  solution, 
or  of  irrigating  the  lower  abdomen  and  pelvis;  the  majority,  however,  agree  with 
Wathen  that  irrigations  are  not  necessary  and  may  be  harmful.  Drainage  should 
be  established  from  the  bottom  of  the  pelvis.  A  cigarette  drain,  with  loose  packing 
of  the  incision  with  gauze,  is  the  most  satisfactory.  Colotomy  is  rarely  necessary, 
but  is  sometimes  indicated  in  cases  where  there  is  great  distention,  due  either  to 
mechanical  obstruction  or  paresis;  it  should  then  be  performed  rapidly  and  in  the 
simplest  manner.  In  such  cases  the  emptying  of  the  intestine  of  gas  according  to  the 
method  suggested  by  Moynihan,^  and  the  use  of  the  Mixter  or  Paul  tube  to  provide 
drainage  of  the  intestine  itself,  are  at  times  of  value. 

The  lateral  incision  may  be  used  in  most  cases  and  gives  the  best  opportunity 
to  find  and  remove  the  appendix;  a  second  suprapubic  incision  being  made,  if  nec- 
essary, and  drainage  established  through  both.  In  women,  pelvic  drainage  through 
the  vagina  is  sometimes  used  in  addition.  In  desperate  cases  a  long  median  inci- 
sion should  be  quickly  made,  the  pus  allowed  to  pour  out,  and  the  lowest  points  of 
infection  drained.  A  small  amount  of  saline  solution  may  be  poured  into  the  peri- 
toneal cavity  or  30  c.c.  of  hot  horse  serum,  as  advised  by  Wathen,  and  the  patient 
placed  in  Fowler's  position.  Saline  solution  may  be  given  subcutaneously  when 
the  patient  is  returned  to  bed;  and  the  practically  continuous  enteroclysis  as  ad- 
vised by  Murphy  may  be  employed.  Gastric  lavage  while  the  patient  is  still  on 
the  operating  table  is  often  beneficial.  Such  patients  should  be  very  freely 
stimulated  by  the  hypodermic  administration  of  strychnin,  camphor,  digitalis, 
caffein,  and  spartein,  and  the  administration  of  whisky  per  rectum,  until  reaction 
occurs. 

Treatment  of  Fistula. — If  the  fistulous  tract  persisting  after  drainage  of  an 
appendical  abscess  is  well  defined  and  contracted,  the  ideal  method  of  treatment 
is  the  excision  of  the  entire  area  with  the  appendix.  In  some  instances  the  safer 
procedure  is  to  make  a  free  incision  and  curet  the  area,  estabhshing  thorough 
drainage. 

Appendicostomy. — This  operation  was  first  described  in  1902  by  Weir,^  who 
made  use  of  it  for  the  purpose  of  treating  an  intractable  ulcerative  colitis.  Since 
that  time  it  has  been  performed  frequently,  its  chief  indications  being:   the  relief 

^  Moynihan,  B.  G.  A.:   "Abdominal  Surgery." 

2  Weir,  R.:     "A  New  Use  for  the  Useless  Appendix,"  etc.,  Med.  Record,  1902,  Ixii,  201. 


APPENDICITIS   IN    RELATION   TO   GYNECOLOGIC   DISEASES.  543 

of  intestinal  distention  in  cases  of  acute  obstruction,  the  treatment  of  obstinate 
diseases  of  the  colon,  and  artificial  feeding.  The  operative  technic  is  as  follows: 
The  appendix  is  brought  out  of  the  abdomen  through  a  small  McBurney  incision 
and  attached  by  its  base  to  the  abdominal  walls.  Care  must  be  taken  to  see  that 
the  lumen  is  patent.  After  adhesions  have  formed,  in  about  twenty-four  hours, 
the  appendix  is  amputated.  The  fistula  may  be  closed  later  by  destroying  the 
mucosa  with  the  Paquelin  cautery,  or  it  may  be  resected  in  the  usual  way. 

Post-operative  Complicatmis. — For  the  consideration  of  the  complications  and 
sequelae  following  operations  on  the  appendix,  see  Chapter  XXVI. 

APPENDICITIS  IN  RELATION  TO  GYNECOLOGIC  DISEASES. 

The  importance  of  the  relationship  between  appendicitis  and  pelvic  affections  in 
women  cannot  be  too  strongly  emphasized.  Diseases  of  the  pelvic  organs  are 
sometimes  the  chief  factor  in  exciting  an  appendical  attack,  and,  what  is  of  the 
greatest  importance,  appendicitis  is  directly  responsible  for  many  cases  of  dysmen- 
orrhea, sterihty,  pelvic  adhesions,  pyosalpinx,  and  ovarian  abscess.  The  confusion 
of  diagnosis  between  the  two  affections  is  of  great  importance,  for  patients  suffering 
from  chronic  appendicitis  are  often  subjected  to  prolonged  treatment  for  supposed 
pelvic  disease;  while,  on  the  other  hand,  cases  of  acute  salpingitis  are  operated  on 
for  appendicitis.  We  would  especially  emphasize  the  fact  that  dysmenorrhea  may 
be  wholly  due  to  chronic  appendicitis,  and  that  in  cases  of  supposed  pelvic  inflam- 
mation in  young  girls  the  appendix  should  always  be  suspected. 

The  relationship  between  appendicitis  and  pelvic  affections  may  be  directly 
causal  or  purely  accidental,  and  the  obvious  classification  of  diseases  of  the  appendix 
from  this  standpoint  is  as  follows : 

1.  Cases  in  which  the  appendical  disease  is  primary  and  the  pelvic  affection 
secondary  or  consecjuent  on  the  lesion  of  the  appendix. 

2.  Cases  in  which  the  gynecologic  affection  is  primary  and  the  disease  of  the 
appendix  secondary. 

3.  Cases  in  which  coexisting  affections  of  the  pelvic  organs  and  appendix  are 
independent  of  each  other. 

In  cases  in  which  the  association  is  accidental,. the  affection  of  the  appendix, 
as  a  rule,  is  an  old  one,  consisting  chiefly  of  the  presence  of  adhesions,  kinking, 
thickening  and  induration  or  atrophy  of  the  walls,  stenosis,  or  obliteration.  On 
the  other  hand,  during  the  course  of  an  operation  for  acute  appendicitis,  unsuspected 
disease  of  the  uterus,  tubes,  or  ovaries  may  be  discovered. 

Pelvic  inflammatory  disease,  the  result  of  direct  propagation  from  a  right  iliac 
abscess,  is  a  common  event,  and  is  more  frequent  in  women  than  in  men.  The 
significance  of  the  accident  in  the  former  is  that  the  uterus  and  its  adnexa,  particu- 
larly the  right  tube  and  ovary,  may  be  implicated  in  the  suppurative  process,  with  a 
resulting  permanent  impairment  of  their  function.  Pus  tubes  and  ovarian  abscesses 
are  not  infrequent  sequelae  of  suppurative  appendicitis,  and  in  less  severe  cases,  the 
pelvic  organs  remain  bound  up  in  adhesions  which  are  a  source  of  persistent  pain, 


544  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 

severe  dysmenorrhea,  and  sterility.  The  pelvic  disease  is  often  limited  to  the  right 
side,  but  the  left  side  may  also  be  implicated. 

Appendicitis  Secondary  to  Pelvic  Inflammation .-_ — In  women  the  appendix  fre- 
quently hangs  down  over  the  brim  of  the  pelvis  and  is  in  contact  with  the  right  ovary, 
tube,  or  broad  ligament;  it  is,  therefore,  readily  involved  in  inflammatory  affections 
of  these  organs.  When  situated  in  the  iliac  fossa,  it  may  also  become  adherent  to  the 
enlarged  tube  or  ovary.  As  a  rule,  in  these  cases,  the  appendix  is  merely  adherent 
by  its  tip,  and  may  present  no  gross  pathologic  lesions,  but  careful  examination 
of  such  appendices  shows  that  comparatively  few  are  perfectly  normal.  A  mild 
chronic  inflammation  is  most  often  met  with,  but  strictures,  obliteration,  and  cystic 
changes  are  not  uncommon. 

Tuberculosis  of  the  pelvic  organs  may  be  transmitted  directly  to  the  appendix 
through  contiguity  of  structure,  or  the  appendix  may  simply  become  adherent  to  the 
tubercular  mass  without  being  invaded  by  the  disease. 

The  appendix  is  frequently  adherent  to  tumors  of  the  ovaries  and  uterus.  Der- 
moids, and  cysts  with  twisted  pedicles,  most  frequently  give  rise  to  intestinal  adhe- 
sions involving  the  appendix.  An  acute  appendicitis  developing  under  such  condi- 
tions may  infect  the  cyst  and  cause  suppuration  of  its  contents. 

Differential  Diagnosis. — The  clinical  history  of  some  pelvic  affections  so 
exactly  simulates  appendicitis  that  a  differential  diagnosis  is  extremely  difficult. 
In  many  cases  the  differential  diagnosis  is  of  importance  chiefly  from  its  bearing 
upon  the  technic  of  the  operation,  as  in  any  case  surgical  intervention  may  be 
imperative,  but  at  other  times  palliative  treatment  may  be  indicated  if  the  case  is 
one  of  pelvic  disease;  whereas,  if  it  is  an  appendical  attack,  delay  may  cost  the 
patient's  Hfe.  The  questions  which  arise  are :  Is  the  case  one  of  appendicitis  ?  is 
it  a  case  of  pelvic  disease  ?  or  do  lesions  of  both  organs  exist  ? 

Inflammatory  diseases  of  the  right  adnexa  are  most  frequently  confounded  with 
appendicitis.  The  chief  reliance  is  to  be  placed  on  the  liistory  of  the  onset  of  the 
attack.  Acute  pelvic  inflammation  is  usually  preceded  by  a  vaginal  discharge  and 
sometimes  dysmenorrhea ;  whereas  in  appendicitis  a  history  of  digestive  disturbances 
or  of  previous  attacks  of  pain  in  the  right  side  is  often  given.  In  appendicitis  the 
initial  pain  is  apt  to  be  colicky  and  general;  while  in  pelvic  disease  it  is  more  steady 
and  less  intense.  The  local  pain  and  tenderness  are  situated  more  deeply  in  the 
pelvis  and  inguinal  region  and  the  most  exquisite  tenderness  is  elicited  by  pressure 
over  Poupart's  ligament.  With  a  supervening  peritonitis  the  differential  diagnosis 
is  practically  impossible. 

Ruptured  extrauterine  pregnancy  and  ovarian  tumor  with  a  twisted  pedicle  are 
frequently  mistaken  for  acute  appendicitis.  The  sudden  acute  onset,  often  accom- 
panied with  nausea  and  vomiting,  is  strikingly  suggestive  of  appendicitis.  The  pain, 
however,  is  seldom  colicky.  An  accurate  account  of  the  events  leading  up  to  the 
attack,  together  with  a  careful  bimanual  examination,  will  usually  make  the  diag- 
nosis perfectly  clear;  sudden  agonizing  pain  at  the  onset,  immediately  followed  by 
fainting,  and  definite  evidence  of  internal  hemorrhage,  are  practically  pathognomonic 


TREATMENT.  545 

of  ectopic  pregnancy.  The  acute  initial  pain  of  appendicitis  may  be  followed  by 
syncope,  but  other  evidence  of  hemorrhage  is  lacking. 

Ovarian  cyst  with  twisted  pedicle  is  usually  easily  recognized  by  means  of  a 
bimanual  examination,  if  necessary,  under  an  anesthetic.  In  all  the  cases  the  most 
important  factor  in  making  a  differential  diagnosis  between  appendicitis  and  pelvic 
disease  is  the  recognition  of  the  fact  that  confusion  may  exist. 

The  diagnosis  of  coexisting  affections  is  often  extremely  difficult,  as  the  symp- 
toms arising  from  the  one  affection  may  completely  mask  the  other.  When  the 
patient  is  known  to  be  suffering  from  some  pelvic  inflammation,  the  development  of 
an  appendical  attack  may  unfortunately  be  attributed  to  an  exacerbation  of  the 
pelvic  disease.  The  greater  severity  of  the  abdominal  and  constitutional  symptoms 
in  appendicitis,  however,  should  suggest  the  complication.  In  doubtful  cases  an 
exploratory  section  entails  less  risk  than  delaying  the  operation  until  the  diagnosis 
is  clear.  In  all  cases  of  pelvic  disease  where  there  is  a  possibility  of  error,  the  abdom- 
inal route  is  preferable  to  the  vaginal.  Acute  appendicitis,  occurring  in  a  patient 
who  is  known  to  be  the  subject  of  an  ovarian  cyst,  naturally  suggests  torsion  of  the 
ovarian  pedicle;  fortunately,  early  abdominal  section  is  indicated  in  either  case. 
The  surgeon  must  be  on  his  guard,  when  a  tumor  or  other  pelvic  affection  is  dis- 
covered during  the  course  of  an  examination  in  a  case  of  appendicitis,  not  to  mistake 
it  for  the  sole  cause  of  the  symptoms;  and,  on  the  other  hand,  a  careful  pelvic  exam- 
ination should  be  made  in  every  case  of  appendicitis. 


TREATMENT. 

An  examination  of  the  appendix  whenever  the  abdomen  is  opened  is  now  the 
routine  procedure  of  practically  all  gynecologists,  except  in  a  few  cases  of  simple 
retroflexion,  where  the  very  small  incision  may  not  afford  an  opportunity  to  find 
the  appendix  unless  it  occupies  the  pelvic  position.  If  there  is  the  slightest  suspi- 
cion of  appendical  trouble,  the  incision  should  be  prolonged  in  any  case,  so  as  to 
bring  the  appendix  into  view. 

The  removal  of  the  normal  appendix  when  the  abdomen  is  opened  for  some 
other  cause  is  not  justifiable  except  in  certain  cases  where  there  is  a  possibility  of 
operation  performed  in  the  neighborhood  giving  rise  to  post-operative  adhesions  in 
which  the  appendix  may  become  involved.  In  all  pelvic  operations  the  intraperi- 
toneal appendix,  pointing  downward,  may  become  adherent  to  the  operative  area. 
Fig.  760  illustrates  a  case  where  the  appendix  became  adherent  in  a  case  of  simple 
suspension  of  the  uterus. 

Incision  for  Removal  of  the  Appendix. — In  the  majority  of  cases  the  operation  is 
performed  primarily  for  the  relief  of  the  pelvic  trouble,  and  the  median  incision  is 
the  best  for  this  purpose.  If  the  abdominal  walls  are  lax  or  if  the  incision  is  8  or 
10  cm.  long,  the  opening  is  easily  drawn  over  to  the  right  side  and  the  iliac  fossa  may 
be  easily  explored.  The  appendix  is  difficult  to  reach  through  a  median  incision  of 
only  4  or  6  cm.,  and  in  such  a  case  the  choice  lies  between  lengthening  the  incision 
VOL.  II — 35 


546 


OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 


or  making  a  second  incision  over  the  appendix.  As  a  rule,  we  prefer  the  second 
incision  in  such  cases,  since,  if  the  appendix  should  happen  to  occupy  the  retrocecal 
position,  or  if  the  cecum  has  a  short  mesentery,  a  lateral  incision  is  usually  necessary. 

The  semilunar  incision  is  the  best  where  coincident  appendicitis  and  right-sided 
pelvic  disease  is  suspected,  or  where  the  diagnosis  is  doubtful  between  right-sided 
pelvic  disease  and  appendicitis. 

Lateral  Incision.— ^Nhen  the  appendix  is  not  easily  reached  through  the  median 
incision,  it  is  advisable  to  make  an  incision  directly  over  the  appendix;  or  when  on 


Fig.  760. — Long  Appendix  Adherent  by  its  Tip  to  the  Suspensory  Ligament  Attaching  the  Uteri's  to  the 

Abdominal  Wall. 
Case  of  myomectomy  and  suspension  of  the  uterus;   subsequent  operation  for  appendical  complications. 

exploring  the  right  iliac  region  through  the  median  incision  a  periappendical  abscess 
is  discovered,  it  is  best  to  open  it  extraperitoneally  by  means  of  an  incision  outside 
of  the  mass,  using  the  median  incision  as  a  guide.  The  median  incision  is  then 
closed,  care  being  taken  to  keep  it  free  from  contamination  throughout  the  course 
of  the  operation. 

Removal  of  the  Appendix. — The  general  rule  to  be  observed  in  connection  with 
the  removal  of  the  appendix  during  the  course  of  a  pelvic  operation  is  that  the  clean 
operation  should  be  done  first.     If  there  is  no  suppuration,  either  operation  may  be 


Fig.  761. — Extkn.sive   Involvement   op  the  Appf^NDix  in   Tubo-ov.\ri.\n  Abscess.      Widespread  Adhesions 

TO  Uterus  and  Pelvic  Walls. 
A,  The  mesappendix  is  tied  off  and  the  appendix  detached  at  its  base  and  grasped  as  shown  in  the  lower 
figure,  then  the  ovarian  vessels  are  exposed  and  tied  at  B.     Lastly,  as  the   appendix,  tube,  and   ovary   are   lifted 
out  of  their  bed  of  adhesions  the  tube  is  exsected  from  the  cornu  at  C.  [547 


548  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 

done  first;  but  it  is  generally  advisable  to  give  precedence  to  the  pelvic  operation. 
If  both  are  infected,  it  is  best  to  remove  the  appendix  at  once,  as  this  must 
be  done. 

In  the  case  of  pelvic  adhesions  involving  the  appendix,  one  of  three  procedures 
mav  be  adopted.  If  the  adhesions  are  light,  they  may  be  separated  and  the  two 
conditions  treated  independently,  but  if  the  appendix  is  densely  adherent  to  the  tube 
or  ovarv,  it  is  better  not  to  try  to  separate  them,  but  to  remove  the  pelvic  organ  and 
appendix  en  masse,  beginning  either  by  clamping  and  dividing  the  cecal  end  of  the 
appendix  and  closing  the  opening  in  the  cecum,  or  by  detaching  the  tubo-ovarian 
mass  and  with  it  the  appendix,  which  is  finally  clamped  and  separated  at  its  base. 

When  the  appendix  coalesces  wnth  the  tube  and  ovary  to  form  a  pelvic  abscess, 
extreme  care  must  be  taken  not  to  distribute  the  infection  over  the  peritoneal  cavity. 
In  the  case  of  a  large  abscess,  if  the  patient  is  in  bad  condition,  it  may  be  advisable 
simply  to  make  a  vaginal  incision  and  evacuate  and  drain  the  cavity,  leaving  the 
appendix  to  be  removed  later.  A  small  abscess  may  be  enucleated  by  first  detach- 
ing the  appendix  from  the  cecum,  then  tying  the  ovarian  vessels  and  the  uterine  end 
of  the  tube,  and  finally  carefully  peeling  out  the  mass. 

When  the  appendix  is  adherent  to  a  uterine  or  ovarian  tumor,  it  may  be  detached 
from  the  growth,  if  the  adhesions  are  light,  and  removed  after  the  tumor;  or,  if  the 
adhesions  are  dense,  it  is  best,  when  possible,  to  free  the  appendix  first  at  the  cecal 
end  and  remove  it  with  the  mass. 

Appendicitis  Complicating  Pregnancy,  Labor,  and  the  Puerperium. — 
The  question  of  the  relation  of  appendicitis  to  pregnancy,  labor,  and  the  puerperium 
demands  especial  consideration  on  account  of  the  diagnostic  difficulties  and  the 
extreme  gravity  of  the  complications  menacing  the  life  of  both  mother  and  child 
which  may  arise.  It  is  only  within  the  last  decade  that  the  importance  of  appendi- 
citis in  women  during  the  child-bearing  age  has  been  recognized.  Abrahams,^  in  1897, 
was  able  to  collect  only  fifteen  cases  from  the  literature,  but  since  that  time  many 
cases  have  been  recorded,  and  it  is  now  pretty  generally  known  that  abdominal 
pain  and  tenderness  developing  during  pregnancy  may  be  due  to  appendicitis,  that 
abortions  may  be  caused,  and  that  puerperal  fever  may  result  from  it.  It  is  not 
necessary  to  assume  a  direct  etiologic  relationship  to  account  for  the  occurrence 
of  appendicitis  during  pregnancy,  and  probably  in  the  majority  of  cases  the 
connection  is  accidental.  The  normal  appendix  is  subject  to  practically  the  same 
conditions  during  pregnancy  as  at  other  times;  as  FrankeP  claims,  an  organ  so 
variable  in  size,  form,  and  position,  and  normally  so  easily  movable,  can  be  easily 
adapted  to  the  varying  conditions  of  pressure  in  the  abdomen.  But  when  the  appen- 
dix has  been  prepared  by  antecedent  disease,  or  when  adhesions  and  kinking  are 
found,  the  alteration  in  its  anatomic  relations  involves  more  or  less  danger  of  exciting 
an  acute  attack.  The  forcible  contraction  of  the  uterus  and  its  sudden  change  in 
position  after  delivery  are  extremely  dangerous  when  the  appendix  is  adherent  to 

^  Abrahams,  R.:     "Appendicitis  Complicating  Pregnancy,"  Am.  Jour.  Obst.,  1897,  xxxv.  205. 
^  Frankel.  E.:   "  Die  Appendicitis  in  ihren  Beziehungen  zur  Geburtshiilfe  und  Gynakologie," 
Sammlung.  klin.  Vort.,  1898,  No.  229,  1335. 


TREATMENT.  549 

the  uterus  or  adnexa,  and  especially  when  the  uterine  wall  forms  part  of  the  wall  of 
an  appendical  abscess. 

The  Effect  of  Appendicitis  upon  Pregnancy. — In  mild  attacks  the  normal  course 
of  the  pregnancy  is  not  disturbed,  but  in  severe  attacks,  unless  cut  short  by  early 
operative  interference,  the  prognosis  is  extremely  grave.  Operations  have  been 
performed  for  suppurative  periappendicitis  and  for  gangrenous  appendicitis  with 
general  peritonitis,  and  the  pregnancy  has  then  gone  on  to  term  and  a  healthy 
child  has  been  born.  Usually,  however,  in  severe  cases  abortion  ensues.  In  some 
cases  the  fetus  dies  in  utero  from  toxemia  or  septicemia,  and  is  then  expelled;  but 
more  frequently  the  uterine  contractions  are  primarily  excited  and  a  living  child  is 
expelled.  If  premature  delivery  occurs  early  in  the  attack,  a  healthy  child  may  be 
born;  but  if  the  patient  has  become  profoundly  septic,  or  if  infection  of  the  uterus 
has  occurred  before  delivery  takes  place,  the  infant  soon  succumbs.  With  the  act 
of  parturition  there  is  the  double  danger  of  the  almost  inevitable  rupture  of  adhe- 
sions, with  the  distribution  of  the  infection,  and  the  danger  of  direct  infection  of  the 
uterus.  It  is  not  the  miscarriage  itself  which  produces  the  fatal  result,  although  it 
is  frequently  followed  by  a  rapidly  fatal  termination,  but  the  general  and  local 
infection  which  induces  the  abortion  also  causes  the  death  of  the  mother. 

The  diagnosis  is  often  difficult.  A  typical  case  is  easily  recognized,  but  if  the 
pain  and  tenderness  are  not  definitely  locahzed,  and  if  constitutional  disturbances 
are  sHght,  the  symptoms  are  often  mistaken  for  threatened  abortion ;  and  if  the  attack 
occurs  during  labor,  the  appendical  symptoms  may  be  attributed  to  the  labor. 
Appendicitis  developing  after  delivery  may  simulate  puerperal  infection,  and  indeed 
may  be  accompanied  by  an  infection  of  the  uterus.  The  differential  diagnosis 
between  appendicitis  during  the  early  months  of  pregnancy  and  a  ruptured  extra- 
uterine pregnancy  may  be  very  difficult.  The  chief  reliance  in  all  cases  must  be 
placed  upon  the  localization  of  the  pain  and  tenderness  in  the  appendical  region. 
During  pregnancy  the  presence  of  marked  constitutional  symptoms,  fever,  and 
accelerated  pulse,  also  speaks  for  appendicitis. ' 

Treatment. — The  most  important  point  in  the  treatment  of  appendicitis  com- 
plicating pregnancy  is  its  prophylaxis.  Every  woman  who  has  suffered  from  an 
attack  of  appendicitis,  however  mild,  should  have  the  appendix  removed,  if  she  is 
liable  to  become  pregnant.  Every  pregnant  woman,  especially  if  she  gives  a  history 
of  antecedent  appendical  disease,  should  be  kept  under  careful  observation,  and  if 
any  symptoms  of  an  appendical  attack  arise,  operative  interference  should  be 
promptly  undertaken  as  soon  as  the  diagnosis  is  reasonably  certain.  The  risk  to 
both  mother  and  child  in  severe  cases  of  appendicitis  during  pregnancy  has  been 
estimated  as  high  as  50  per  cent.;  whereas  with  early  operation  and  removal  of 
the  appendix  before  suppuration  or  gangrene  have  supervened,  the  risk  to  the 
mother  is  almost  n  il  and  the  pregnancy  proceeds  normally  in  practically  all  cases. 
When  abortion  follows  the  operation,  it  is  due  to  some  complication  necessitating 
the  manipulation  of  the  uterus,  or  is  the  result  of  the  disease.  If  the  ]\IcBurney 
incision  is  closed  without  drainage,  there  is  no  weakness  of  the  abdominal  walls 


550  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 

to  be  feared.  A  localized  abscess  should  be  treated  by  incision  and  drainage, 
as  little  manipulation  as  possible  being  employed.  The  pregnancy  may  advance 
to  term,  but  abortion  is  liable  to  occur,  and  the  danger  of  infection  of  the  uterus 
and  of  imperfect  contraction  and  post-partum  hemorrhage  then  are  added. 

Toward  the  end  of  pregnancy  the  question  is  more  perplexing.  An  unnecessary 
operative  interference  at  this  time  is  not  so  harmless  a  procedure  as  in  early  preg- 
nancy. Operation  at  this  time  is  more  apt  to  induce  labor,  and  it  is  somewhat  more 
difficult  to  perform  if  the  appendix  is  not  easily  accessible;  the  recent  McBurney 
incision  may  give  way,  and  labor  may  be  prolonged,  as  the  force  of  the  abdominal 
muscles  is  impaired.  If  the  patient  is  suffering  from  a  definite  appendical  attack, 
however,  a  timely  operation  involves  far  less  risk  than  allowing  the  disease  to  progress. 
Moreover,  even  if  the  attack  should  subside,  adhesions  may  have  formed  which 
later,  with  the  advent  of  labor,  may  give  rise  to  further  trouble. 

Appendicitis  developing  during  the  first  few  days  of  the  puerperium  closely 
simulates  puerperal  infection.  The  localization  of  the  pain  and  tenderness  associ- 
ated with  nausea  and  vomiting  usually  lead  to  a  correct  diagnosis,  especially  when 
there  is  a  history  of  previous  appendical  attacks.  Prompt  surgical  interference 
should  be  made  as  soon  as  the  diagnosis  is  reasonably  certain. 


SPECIFIC  INFLAMMATORY  DISEASES  OF  THE  APPENDIX. 

Specific  inflammatory  diseases  of  the  appendix  include  typhoid  fever,  tubercu- 
losis, actinomycosis,  and  amebic  dysentery. 

Appendicitis  in  Typhoid  Fever. — Appendicids  may  be  related  to  typhoid  fever 
in  the  following  ways : 

1.  The  appendicitis  may  be  an  accidental  accompaniment  of  typhoid  fever, 
or  a  latent  or  chronic  appendicitis  may  be  roused  into  activity  by  typhoid  fever. 

2.  A  true  typhoid  infection  of  the  appendix  may  produce  symptoms  resembling 
a  simple  acute  inflammation,  and  naturally  may  go  on  to  perforation.  The  typhoid 
infection  of  the  appendix  may  be  accompanied  by  a  secondary  infection  with  the 
ordinary  pyogenic  micro-organisms. 

3.  Appendicitis  may  develop  so  soon  after  the  subsidence  of  typhoid  fever  that 
a  causal  relationship  is  suggested;  or  latent  germs  harbored  in  the  appendix  may 
cause  an  appendical  attack  at  a  more  or  less  remote  period. 

It  is  generally  stated  that  the  appendix  is  involved  in  about  one-third  of  all 
cases  of  typhoid  fever,  and  that  perforation  of  the  appendix  forms  5  per  cent,  of 
the  typhoid  perforations.  Typhoid  lesions  in  the  appendix  vary  greatly  in  extent 
and  severity.  In  the  majority  there  is  merely  a  slight  congestion;  in  others,  the 
whole  appendix  is  swollen  and  turgid  and  the  lumen  practically  obliterated  by  the 
swollen  mucosa  and  submucosa.  Typical  typhoid  lesions  with  or  without  ulcera- 
tion are  found  in  the  tissues.  Where  there  is  ulceration,  a  secondary  invasion  with 
pyogenic  bacteria  is  liable  to  occur,  and  an  acute  suppurative  appendicitis  develops. 
The  simple  typhoid  lesions  in  the  appendix  may  go  on  to  perforation  or  may  undergo 


SPECIFIC    INFLAMMATORY   DISEASES    OF   THE   APPENDIX. 


551 


a<; — 


b-'- 


the  usual  reparative  changes.  The  development  of  a  pyogenic  infection  during 
the  course  of  typhoid  fever  is  not  different  from  an  uncomplicated  appendicitis. 
The  development  of  an  appendical  attack  after  the  subsidence  of  typhoid  fever  may 
be  a  mere  coincidence,  but  it  is  possible  that,  as  in  the  case  of  the  gall-bladder, 
the  typhoid  germ  may  be  harbored  in  the  appendix  longer  than  in  the  general 
intestinal  tract,  and,  remaining  latent  for  a  longer  or  shorter  period,  may  finally 
determine  a  subacute  or  an  acute  local  inflammation. 

The  Symptoins  and  Diagnosis. — The  decision  for 
or  against  operation  for  appendicitis  in  a  patient  who 
has  typhoid  fever  is  of  extreme  gravity.  At  the 
outset  of  the  illness,  when  the  symptoms  are  not 
fully  developed,  the  first  question  to  be  answered  is: 
Has  the  patient  appendicitis  or  has  he  typhoid  fever  ? 
In  some  cases  an  immediate  answer  cannot  be  given, 
but  when  there  is  reason  to  suspect  typhoid  fever  and 
any  of  the  typical  symptoms  of  appendicitis  are  lack- 
ing, the  case  should  be  kept  under  the  closest  observa- 
tion, and  every  available  means  used  to  arrive  at  a 
decision.  Typhoid  fever  may  be  marked  at  the  outset 
by  localized  pain,  tenderness,  and  rigidity,  with  fever, 
but,  as  a  general  thing,  the  tenderness  elicited  on 
pressure  is  not  so  exquisite  as  in  acute  appendicitis. 
Rolleston,^  as  a  result  of  numerous  observations, 
believes  that  the  absence  of  the  abdominal  reflex  in 
the  presence  of  pyrexia  excludes  appendicitis  and  is 
suggestive  of  enteric  fever.  The  expression  of  the 
patient  and  the  character  of  the  fever  are  valuable 
aids  in  reaching  a  diagnosis.  The  leukocyte  count 
is  of  great  value  in  making  a  differential  diagnosis 
between  the  two  affections.  In  typhoid  fever  the 
leukocytes  are  not  increased  and  there  may  be  a 
distinct  leukopenia;  the  mononuclear  cells,  especially 
the  large  ones,  are  increased;  while  in  appendicitis 
the  polymorphonuclears  are  increased.  The  Widal 
reaction  is  obtained  too  late  to  be  of  value  in  these 
cases.     Perforation  of  a  typhoid  ulcer  may  exactly 

simulate  acute  appendicitis.  As  immediate  operation  is  indicated  in  either  case,  a 
differential  diagnosis  is  of  less  importance. 

Treatment. — Where  there  is  a  question  as  to  the  true  condition,  operation  should 

be  delayed  until  no  possibility  of  a  mistake  remains,  unless  urgent  symptoms  arise. 

When  appendicitis  develops  in  the  course  of  a  typhoid  fever,  it  should  be  the  rule 

not  to  operate  during  the  first  ten  days,  in  the  absence  of  urgent  symptoms,  and  not 

'  Rolleston:     "The  Abdominal  Reflex  in  Enteric  Fever,"  Brain,  1906,  cxiii. 


^> 


Fig.  762. 


Typhoid  Appendix,  Elev- 
enth Week. 
o,  Healed    ulcer;    b,   more    recent 
superficial  ulcer.?  covered  with  exudate; 
c,  mass  of  partially  organized  exudate. 


552  OPERATIONS    FOR   DISEASES    OF   THE    VERMIFORM    APPENDIX. 

at  all  during  the  course  of  the  disease  if  the  appendicitis  is  apparently  of  a  mild 

type- 
Tuberculosis  of  the  appendix  may  be  primary  or  secondary,  the  latter  condi- 
tion being  due  to  direct  extension  by  continuity  from  the  cecum;  or  to  transplanta- 
tion of  the  infective  organism  from  some  distant  organ,  usually  the  lungs,  in  which 
case  the  tuberculous  lesion  may  be  disseminated  throughout  the  entire  intestinal  tract 
or  may  be  limited  to  the  appendix.  In  most  instances  appendical  tuberculosis  is 
merely  part  of  an  ileocecal  infection.  Miliary  tuberculosis  of  the  serous  surface  due 
to  infection  by  contiguity  or  continuity  from  the  general  peritoneum,  the  pelvic 
organs,  or  some  other  focus,  is  comparatively  frequent,  but  possesses  little  practical 
interest,  apart  from  the  fact  that  tuberculous  adhesive  bands  may  cause  a  twist  or 
stricture  of  the  appendix.  Primary  intestinal  tuberculosis  limited  to  the  appendix 
is  apparently  extremely  rare,  though  probably  not  so  rare  as  it  seems  to  be,  as  in 
many  cases  the  tuberculous  nature  of  the  appendical  inflammation  is  only  recog- 
nized by  the  microscope;  and,  on  the  other  hand,  it  is  possible  that  in  some  cases 
where  there  was  a  more  generalized  process,  the  appendix  was  the  starting-point  of 
the  infection. 

Primary  tuberculosis  of  the  appendix  presents  two  distinct  types:  the  usual 
ulcerative,  caseous,  or  fibrocaseous  form,  and  the  hyperplastic  form.  The  ordinary 
variety  of  tuberculous  appendix  resembles  a  simple  subacute  or  chronic  appendicitis. 
The  serous  surface  may  show  a  few  miliary  foci,  and  on  examination  of  the  mucosa 
typical  ulcers  are  usually  found.  The  appendix  is  little,  if  at  all,  larger  than  normal, 
and  may  even  appear  more  or  less  atrophic.  The  lumen  may  be  distended  with 
caseous  material. 

Hyperplastic  tuberculosis  of  the  cecum  is  well  known,  but,  as  a  rule,  the  appendix 
is  not  afi^ected,  and  with  the  exception  of  Crowder's^  case  (Fig.  763),  we  have  found  no 
cases  reported  in  which  the  affection  apparently  originated  in  the  appendix.  This 
variety  of  tuberculosis  is  characterized  by  the  enormous  hypertrophy  of  the  intestinal 
walls,  usually  associated  with  narrowing  of  the  lumen.  The  normal  contour  of  the 
part  is  usually  well  preserved;  cicatricial  contractions,  however,  may  produce  shght 
irregularities  in  form,  and  masses  of  fat  in  the  outer  layers  may  cause  irregular  eleva- 
tions on  the  surface.  Histologically,  the  most  conspicuous  feature  is  the  general 
fibrous  proliferation  affecting  all  the  tissues,  but  most  pronounced  in  the  submu- 
cosa.  Lymphoid  cells  are  abundant,  occurring  in  clumps  and  singly.  Epithelioid 
cells  and  caseation  may  be  entirely  lacking,  but  microscopic  tubercles  are  usually 
found  in  places.  The  lesion  is  essentially  that  of  a  chronic  productive  inflammation 
associated  with  a  tuberculous  process^.  Tubercle  bacilli  are  usually  scanty,  but  may 
be  abundant.  The  disease  is  essentially  chronic,  and  the  hyperplastic  process  is 
explained  by  Crowder  as  a  conservative  effort  on  the  part  of  the  tissues  to  resist 
the  growth  and  invasion  of  the  bacilli. 

Clinical  History. — AYhile  the  affection  is  limited  to  the  appendix  there  are  no 

'  Kelly,  H.  A.,  and  E.  Hurdon:  "The  Vermiform  Appendix  and  Its  Diseases,"  pages  338 
and  763. 


SPECIFIC    INFLAMMATORY    DISEASES    OF   THE   APPENDIX.  553 

signs  or  symptoms  by  which  it  can  be  distinguished  from  simple  appendicitis. 
The  disease  is  chronic  in  its  course,  but  finally  there  is  extensive  invasion  of  the 
ileocecal  region,  and  the  appendical  symptoms  are  masked  by  those  of  a  more  pro- 
nounced character  produced  by  the  cecal  affection. 

The  treatment  of  tuberculous  appendicitis  is  precisely  the  same  as  that  of  simple 
appendicitis,  especial  attention,  however,  being  directed  to  the  condition  of  the 
adjacent  portion  of  the  cecum,  and  the  inguinal  lymph-glands.  The  treatment  of 
the  tuberculous  appendix  when  it  is  a  part  of  an  ileocecal  infection  is  considered 
elsewhere. 

Actinomycosis. — The  appendix  is  usually  considered  to  be  the  chief  portal 
of  entry  for  the  infective  agent  in  abdominal  actinomycosis.  Pure  actinomycotic 
infection  in  man  excites  merely  a  chronic  productive  inflammation,  but  as  the 
micro-organism  enters  the  tissues  through  a  cavity  beset  with  bacteria,  a  secondary 
infection  producing  suppuration  is  an  almost  constant  accompaniment.     In  the 


Fig.   763. — Hyperplastic  Tuberculosis   of  the  Appendix. 

In   the  cross-section   tubercles   {a^   appear   as   deeply   stained   nodules. 
\ 

early  stages  the  products  of  the  infection  appear  as  a  brawny,  pseudo-fluctuant, 
tumor  mass,  which,  after  a  longer  or  shorter  period,  ceases  to  be  localized  and  invades 
neighboring  structures,  forming  indurated  masses  accompanied  by  an  edematous 
condition  of  the  surrounding  tissues.  The  disease  spreads  in  all  directions,  and 
finally  invades  the  abdominal  walls,  usually  resulting  in  the  formation  of  multiple 
fistulse.  Embolic  infection  by  way  of  the  blood-vessels  sometimes  occurs.  The 
small  irregular  cavities  distributed  throughout  the  dense  scar-like  masses  are  lined 
with  soft  reddish-brown  granulations,  which  are  bathed  in  a  scanty,  puriform  fluid 
containing  the  characteristic  yellowish  actinomycotic  granules. 

Etiology. — The  disease  is  probably  contracted  from  grain  or  from  infected  ani- 
mals, and  is  most  commonly  found  in  farmers,  cattlemen,  and  those  concerned 
with  the  management  of  live  stock  or  grain.  There  may  be  a  definite  history  of 
caring  for  infected  animals,  and  a  grain  of  wheat  or  barley  has  been  found  in  the 
midst  of  the  actinomycotic  mass.     Men  are  more  frequently  attacked  than  women, 


554  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 

probably  on  account  of  the  difference  in  their  daily  avocations.  The  disease  is 
most  common  during  middle  life.  It  may  run  a  rapid  course,  one  case  lasting  only 
four  weeks,  but  it  is  usually  chronic  and  continues  for  years,  the  early  lesions  showing 
a  reparative  process,  while  new  foci  are  developing  elsewhere.  The  clinical  symp- 
toms at  the  outset  resemble  those  of  acute  appendicitis,  but  after  the  acute  symptoms 
have  subsided,  a  tender  swelling  persists  in  the  right  side.  As  the  disease  advances 
there  is  a  progressive  increase  in  the  size  of  the  mass,  associated  with  a  characteristic 
brawny  induration  of  the  skin.  Neighboring  structures  are  involved  by  contiguity 
or  continuity,  and  in  some  cases  metastases  occur.  Finally,  sinuses  form  in  various 
regions.  The  temperature,  which  is  only  slightly  elevated  at  first,  later  becomes 
septic  in  character,  and  there  are  frequent  chills.  The  leukocytes  may  be  almost 
normal  or  there  may  be  a  marked  leukocytosis.  The  diagnosis  is  verified  by  finding 
the  characteristic  yellow  granules  in  the  abscess  foci,  and  the  demonstration  under 
the  microscope  of  the  fungus. 

Treatment. — Early  removal  of  the  appendix  with  resection  of  the  adjacent  por- 
tion of  the  cecum,  if  at  all  infiltrated,  may  cut  short  the  attack.  Usually,  however, 
the  disease  is  too  far  advanced  for  complete  enucleation,  and  the  chief  reliance  must 
be  placed  upon  the  widest  possible  excision,  and  thorough  curetting  and  drainage  of 
remaining  cavities.  The  administration  of  potassium  iodid  in  large  quantities  is  a 
useful  aid  in  controlling  the  disease. 

Amebic  Dysentery. — The  appendix  vermiformis  is  often  severely  affected  in 
cases  of  amebic  dysentery,  the  perforation  of  an  amebic  ulcer  in  the  appendix 
sometimes  causing  a  fatal  peritonitis  (Roger ^).  The  earliest  lesions  consist  of 
small  reddish  elevations  with  yellowish  centers.  These  soon  develop  into  round  or 
oval  ulcers,  which  later  lose  their  regular  form  and  appear  as  long,  irregular  ulcers, 
filled  with  gelatinous  material,  or  as  thickened,  raised  patches  with  light  yellow  or 
tawny,  ragged  sloughs.  The  ulcers  may  undergo  resolution,  a  patch  of  scar  tissue 
remaining,  or  perforation  may  occur.  The  diagnosis  has  not  been  made  during 
life,  as  the  appendical  affection  is  masked  by  the  disease  of  the  colon. 


NEOPLASMS. 
Primary  tumors  of  the  appendix  are  infrequent,  and  its  secondary  invasion  by 
tumors  originating  elsewhere  is  extremely  rare.  By  far  the  greatest  number  of 
appendical  tumors  described  are  carcinomata.  A  few  isolated  cases  of  benign 
tumors  have  been  observed,  and  include  three  myomata,  two  fibromata,  two  myxo- 
mata,  a  lipoma,  and  a  few  cases  of  mucous  polypi,  probably  of  inflammatory  origin. 
These  tumors  were  of  small  size  and  were  all  discovered  accidentally.  There  are 
five  cases  of  sarcoma  recorded,  three  of  which  were  undoubtedly  primary  in  the 
appendix,  and  two  designated  as  endothelioma.  The  appendix  may  also  be  involved 
in  cases  of  lymphatic  tumors,  where  multiple  foci  of  disease  exist,  as  in  Hodgkin's 
disease. 

*  Roger:    Loc.  cit. 


NEOPLASMS. 


555 


Carcinoma. — There  are  about  seventy  cases  of  primary  cancer  of  the  appendix 
on  record,  in  most  of  which  the  diagnosis  was  verified  by  the  microscope.  In 
every  case  the  tumor  was  discovered  only  after  operation  or  at  autopsy,  and  in 
many  of  the  operative  cases  the  nature  of  the  disease  was  not  recognized  until  the 
microscopic  examination  was  made.  In  five  cases,  or  12  per  cent.,  secondary 
growths  were  present,  but  in  the  remaining  cases  the  tumor  was  limited  to  the  appen- 


foration 


Concr.  taTLp 


Pig.  764. — Carcinoma  of  the  Appendix  Causing  Acute  Perforative  Appendicitis. 


dix.  In  about  half,  the  tumor  was  situated  at  or  near  the  tip  of  the  appendix  and 
appeared  as  a  small,  hard  nodule,  varying  from  the  size  of  a  pea  to  that  of  a  marble. 
In  one  or  two  cases  there  was  a  diffuse  growth  without  definite  limitations.  When 
the  tumor  was  situated  in  the  middle  or  proximal  parts  of  the  appendix,  the  canal  was 
usually  encroached  upon,  or  even  completely  obstructed.  Histologically,  there 
were  a  few  examples  of  cylindric-cell  carcinoma,  but  the  majority  of  the  tumors  were 
made  up  of  solid  clumps  of  small  spheroidal  or  polymorphous  cells,  having  sharply 


556  OPERATIONS    FOR   DISEASES    OF   THE   VERMIFORM   APPENDIX. 

stained  vesicular  nuclei,  and  often  showing  a  conspicuous  vacuolization  of  the  cell 
(basal-cell  carcinoma).  The  tumors  of  this  variety,  comprising  about  half  the  cases, 
all  occurred  in  young  individuals,  having  an  average  age  of  about  twenty-four  years. 
They  are  apparently  benign  in  their  course,  as  no  case  of  recurrence  has  been  ob- 
served, although,  as  a  rule,  the  growth  had  invaded  the  peritoneal  coat  of  the  appen- 
dix. In  the  five  cases  of  cancer  in  which  the  disease  had  extended  beyond  the  appen- 
dix, we  are  not  aware  that  any  were  of  this  nature.  In  several  cases  patients  have 
been  operated  on  again  for  some  other  affection  two  or  three  years  later,  and  no  evi- 
dence of  recurrence  has  been  noted.  In  the  case  of  cylindric-cell  carcinoma  the 
ages  of  the  patients  corresponded  with  that  at  which  intestinal  carcinoma  usually 
develops,  and  extension  of  the  growth  beyond  the  limits  of  the  appendix  is  fre- 
quent. Colloid  carcinoma  also  occurs  in  the  appendix,  and,  like  the  cylindric- 
cell  variety,  develops  in  persons  of  advanced  years. 

The  usual  cHnical  history  is  that  of  some  form  of  appendicitis.  In  several  cases 
perforation  occurred,  usually  at  a  point  beyond  the  obstruction  produced  by  the 
growth,  and  symptoms  of  peritonitis  developed.  In  three  cases,  after  a  long  his- 
tory of  chronic  right  ihac  disease,  a  fecal  fistula  formed,  which  later  was  lined  with 
malignant  granulations. 

Treatment. — Excision  of  the  appendix  in  the  majority  of  cases  results  in  a  per- 
manent cure.  If  the  growth  is  situated  in  the  proximal  part  of  the  appendix, 
the  adjacent  portion  of  the  cecum  should  be  resected  and  the  retrocecal  glands 
should  be  carefully  inspected  and  removed  if  there  is  any  evidence  of  disease. 
If  the  cancer  is  of  the  cylindric-cell  or  colloid  variety,  the  widest  possible  enucleation 
should  be  made,  including  a  large  portion  of  the  cecum  and  all  the  retrocecal  tissues. 

Hernia  of  the  Appendix. — The  appendix  may  form  part  of  the  contents  of 
almost  any  form  of  hernia,  including  both  right  and  left  inguinal,  umbilical,  ob- 
turator, and  femoral  hernias.  It  is  most  frequently  found  in  a  right  inguinal  hernia 
and  may  form  the  sole  contents  of  the  sac.  It  is  liable  to  become  adherent,  acutely 
inflamed,  or  strangulated.  In  some  instances  the  small  cylindric  body  may  be  felt, 
but,  as  a  rule,  a  diagnosis  cannot  be  made  before  operation. 

The  only  treatment  is  the  radical  cure  of  the  hernia,  accompanied  by  resection 
of  the  appendix,  which  is  usually  readily  performed  through  the  hernial  ring.  It  is 
not  advisable  to  return  even  an  apparently  normal  appendix  to  the  abdomen,  as 
the  proximal  end  is  often  diseased. 


CHAPTER  XXXVI. 

SURGERY  OF  THE  PANCREAS. 
By  Eugene  L.  Opie,  M.D, 

Historical. — Twenty-five  years  ago  operations  upon  the  pancreas  were  un- 
known. In  1881  Bozeman^  successfully  extirpated  a  cyst  of  the  pancreas,  and  the 
same  year  Kulenkampff  ^  treated  this  disease  by  incision  and  drainage.  Gussen- 
bauer^  the  following  year  operated  upon  a  cyst  of  the  pancreas  by  stitching  it  to  the 
abdominal  wall,  emptying  the  contents  after  incision  and  packing  with  gauze.  A 
large  proportion  of  all  pancreatic  operations  have  been  performed  upon  cysts  by 
this  method  or  upon  peri-pancreatic  abscesses  by  almost  identical  procedures.  In 
1886  Senn*  demonstrated  by  systematic  experiments  on  the  dog  that  incised  wounds 
of  the  gland  healed  readily,  whereas  pancreatic  substance  injured  by  crushing  was 
absorbed,  provided  the  seat  of  injury  remained  aseptic.  Brunner  (1709)  had  success- 
fully extirpated  part  of  the  pancreas  in  animals,  but  von  Mering  and  Minkowski^ 
first  succeeded  in  keeping  animals  alive' after  total  extirpation  of  the  gland  until 
death  ensued  as  the  result  of  diabetes  mellitus.  Removal  of  a  solid  tumor  of  the 
pancreas  was  successfully  accomplished  by  Trendelenburg,"  who  extirpated  the  tail 
and  body  of  the  gland  invaded  by  sarcoma.  Acute  hemorrhagic  and  gangrenous 
pancreatitis  has  been  treated  by  surgical  methods,  while  in  two  instances  pancreatic 
calculi  have  been  removed  from  the  duct  of  Wirsunff. 

The  difficulty  of  diagnosis  of  pancreatic  disease  and  the  inaccessibility  of  the 
gland,  which  is  in  intimate  relation  with  a  variety  of  vital  structures,  have  greatly 
diminished  the  possibilities  of  purposeful  surgical  interference.  A  large  proportion 
of  operations  upon  the  pancreas,  those  performed  for  the  relief  of  cysts  being  ex- 
cepted, have  been  completed  after  pancreatic  disease  has  been  discovered  at  opera- 
tion undertaken  for  the  purpose  of  exploration  or  as  the  result  of  a  mistaken  diag- 
nosis.    The  recorded  experience  of  a  surgeon  has  usually  been  small;    INIikulicz^ 

1  Bozeman,  N.:  "Removal  of  a  Cyst  of  the  Pancreas  Weighing  T\Yenty  and  One-half 
Pounds,"  New  York  Med.  Rec,  1882,  xxi. 

2  Kulenkampff,  D.:     "Ein  Fall  von   Pancreas-Fistel,"  Berliner  klin.  Woch.,  1882,  xix,  102. 
^  Gussenbauer,  Carl:    "Zur  operativen  Behandlung  der  Pankreas-Cysten,"  Arch.  f.  klin.  Chir., 

1883,  xxix,  355. 

*  Senn,  N.:  "The  Surgery  of  the  Pancreas."  Amer.  Jour,  of  the  Med.  Sciences,  1886,  xcii, 
141,  423. 

^  Mering,  J.  von,  and  Minkowski,  O.:  "Diabetes  meUitus  nach  Pankreasexstirpation,"  Arch, 
f.  exper.  Path.  u.  Phar.,  1889,  xxvi,  371. 

"  Described  by  Witzel:   Deutsche  Zeit.  f.  Chir.,  1886,  xxiv,  326. 

^  Mikulicz,  Joh.  von:  "Surgery  of  the  Pancreas,"  Trans,  of  the  Cong,  of  Amer.  Phvs.  and 
Surg.,  1903,  vi,  55. 

557 


558 


SURGERY   OF   THE   PANCREAS. 


cites  the  exceptional  number  of  sixty  operations  performed  during  a  period  of  twelve 
years. 

Surgical  Anatomy. — Attached  to  the  posterior  abdominal  wall  and  in  front 
of  the  aorta  the  pancreas  occupies  the  posterior  wall  of  the  lesser  peritoneal  cavity. 
Inflammatory  disease  of  the  pancreas  is  almost  invariably  communicated  to  the 
overlying  peritoneal  surface,  and  peritonitis,  limited  in  most  instances  to  the  lesser 
peritoneum,  results.  Accumulation  of  inflammatory  exudate  in  the  bursa  omentahs 
after  closure  of  the  foramen  of  Winslow  by  adhesions  not  infrequently  produces  a 


<£■  -  —  <S  ?■  ^/^V/ 


Fig.  765. — Showing  the  Anatomy  of  the  Pancreatic  DncTS  and  Posterior  Relations  of  the  Pancreas 

IN  A  Boy. 


tumor  palpable  externally  and  other  symptoms  not  infrequently  referred  to  the 
gland  itself. 

The  head  of  the  pancreas,  lying  within  the  duodenal  loop  and  in  immediate 
contact  with  the  blood-vessels,  of  which  the  integrity  is  essential  to  this  part  of  the 
intestine,  is  firmly  attached  to  the  tissues  overlying  the  vertebral  column.  The  bile- 
duct  in  fifteen  subjects  (Helly  ^)  passed  along  a  groove  upon  the  surface  of  the  gland, 
while  in  twenty-five  individuals  it  was  wholly  surrounded  by  glandular  tissue. 

Since  the  splenic  vein  with  the  splenic  artery  passes  along  the  upper  margin  of  the 
*  Helly:  "Beitrag  zur  Anatomie  des  Pankreas,"  Arch.  f.  mik.  Anat.,  1898,  lii,  773. 


SURGICAL   ANATOMY, 


559 


gland,  and  supplies  it  with  numerous  branches,  while  the  superior  mesenteric  vein 
occupies  a  groove  upon  the  posterior  surface  of  the  head,  inflammatory  lesions  of 
the  pancreas  not  infrequently  cause  thrombosis  of  both  these  vessels  and  of  the 
portal  vein.  Kronlein  ^  has  shown  that  the  median  colic  artery  in  a  small  proportion 
of  cases  arises  from  the  superior  mesenteric  near  its  origin ;  and  in  a  case  which  he 
describes  ligation  of  the  artery  during  the  removal  of  carcinoma  of  the  pancreas 
was  followed  by  gangrene  of  the  colon,  In  most  instances  the  artery  arises  at  some 
distance  from  the  gland  and  is  not  a  source  of  danger. 


BviTsa. 
omentAlis 


Transve 
Colon 


Fig.  766. — Relation  of  the  Pancreas  to  the  Lesser  Peritoneal  Cavity  (after  Braune). 


Since  the  tail  of  the  pancreas  is  less  intimately  bound  to  the  surrounding  struc- 
tures, it  permits  greater  movement  of  cysts  and  tumors  arising  in  this  part  of  the 
organ,  and,  serving  as  a  pedicle,  facilitates  their  removal.  Extirpation  of  cysts 
and  solid  tumors  has,  with  few  exceptions,  been  limited  to  those  situated  in  this 
part  of  the  gland.  Since  section  and  closure  of  the  duct  are  followed  by  chronic 
inflammation,  subsequent  injury  to  the  gland  is  least  when  the  distal  part  of  the 
pancreas  is  implicated. 

The  pancreas  may  be  exposed  by  operation  (1)  through  the  peritoneal  cavity, 
in  which  case  the  greater  peritoneal  cavity  is  opened  and  the  lesser  cavity  entered 

'  Kronlein,  R.  N.:  "Klinische  und  topographisch-anatomische  Beitrage  zur  Chirurgie  des 
Pankreas,"  Beit.  z.  klin.  Cliir.,  1895,  xiv,  663. 


560 


SURGERY    OF   THE   PANCREAS. 


(a)  usually  through  the  gastrocolic  ligament  between  stomach  and  colon,  the  great 
omentum  being  pushed  upward  or  penetrated;  (6)  when  the  lesion,  such  as  a  cyst, 
a  tumor,  or  an  abscess,  is  situated  in  the  upper  part  of  the  head  of  the  pancreas, 
it  may,  with  increasing  size,  present  above  the  lesser  curvature  of  the  stomach  be- 
tween liver  and  stomach,  and  is  most  accessible  by  incision  through  the  gastro- 
hepatic  omentum;  (c)  in  some  instances,  particularly  where  cysts,  usually  arising 
from  the  tail  of  the  pancreas,  force  their  way  into  the  transverse  mesocolon,  the 
lesion  may  be  reached  by  carefully  avoiding  the  blood-vessels  through  the  lower 
layer  of  the  mesocolon  after  pushing  upward  the  omentum.  The  pancreas  may 
be  exposed  (2)  extraperitoneally  through  the  lumbar  region :  (a)  the  tail  of  the  gland 


Fig.  767. — Horizontal  Section  of  Body  at  the  Level  of  the  Pancreas. 


is  accessible  through  the  left  lumbar  region  and  drainage  of  peri-pancreatic  abscesses, 
particularly  those  which  have  sunk  downward  by  erosion  of  the  retroperitoneal 
tissue,  has  been  accomplished  by  the  same  route;  (b)  cysts  and  abscesses  of  the 
head  of  the  pancreas  pushing  their  way  to  the  right  have  occasionally  been  found 
accessible  through  the  right  lumbar  region. 

General  Pathology. — Since  the  pancreas  is  richly  supplied  with  blood-vessels 
which  are  distended  when  the  gland  is  secreting  actively,  hemorrhage  after  injury 
is  controlled  with  difficulty.  Deep  sutures  into  the  glandular  parenchyma  by 
occluding  blood-vessels  may  cause  necrosis  of  glandular  tissue,  and  by  occluding 
ducts  may  cause  chronic  inflammation  of  the  tissue  drained  by  those  ducts  which 
have  been  obstructed.     An  even  greater  danger  is  referable  to  the  peculiar  physi- 


GENERAL    PATHOLOGY.  561 

ology  of  the  gland  which  furnishes  a  proteolytic  enzyme  so  active  that  it  is  capable 
of  eroding  the  skin  in  the  neighborhood  of  a  pancreatic  fistula. 

It  is  not  improbable  that  partially  necrotic  pancreatic  tissue  which  is  undergoing 
auto-digestion  is  even  more  toxic  than  products  of  secretion.  Ligation  of  a  part  of 
the  pancreas  in  such  a  way  as  to  occlude  its  circulation  and  produce  necrosis,  accord- 
ing to  Doberauer/  causes  death  in  dogs  within  seven  days.  There  are  so-called 
fat  necroses  and  subserous  hemorrhages  and  the  peritoneal  cavity  contains  hemor- 
rhagic exudate.  Pancreatic  tissue  of  one  animal,  which  has  been  subjected  to  the 
operation,  introduced  into  the  peritoneal  cavity  of  a  second  animal  causes  the  same 
fatal  result.  Necrosis  of  fat  caused  by  contact  of  pancreatic  secretion  with  adipose 
tissue  further  demonstrates  the  injurious  effects  of  products  of  secretion  which  may 
escape  into  a  wound  impHcating  the  gland.  Nevertheless,  products  of  secretion 
can  to  a  certain  extent  be  absorbed  and  rendered  harmless;  the  normal  blood-serum, 
it  is  well  known,  exhibits  active  antitryptic  action. 

The  escape  of  pancreatic  juice  into  the  peritoneum  and  its  irritant  action,  refer- 
able in  considerable  part  to  trypsin,  offers  conditions  w^hich  favor  the  multiplica- 
tion of  bacteria  introduced  at  the  time  of  operation ;  general  peritonitis  may  occur, 
particularly  since  a  variety  of  pancreatic  lesions  are  followed  by  invasion  of  bacteria 
from  the  duodenum.  ^Mikulicz  cites  from  his  own  experience  ninety-one  cases  of 
resection  of  the  stomach  for  gastric  cancer,  with  no  injury  to  the  pancreas;  twenty- 
five,  or  27.5  per  cent.,  died  as  a  result  of  the  operation.  In  thirty  cases  the  pancreas 
was  injured,  the  torn  parenchyma  being  exposed  by  separating  adhesions  between 
the  tumor  and  pancreas.  The  fatal  result  in  twenty-one  of  these  cases,  70  per  cent., 
was  not  referable,  according  to  Mikulicz,  to  the  greater  severity  of  the  operation, 
because  in  most  of  the  cases  death  was  the  result  of  peritonitis. 

The  necessity  for  drainage  by  tampons  of  gauze,  when  there  is  a  possibility  of 
the  escape  of  pancreatic  secretion  into  the  peritoneal  cavity,  is  demonstrated  by  the 
statistics  of  the  same  surgeon.  In  twenty-seven  cases  of  acute  disease  of  the  pan- 
creas described  in  the  literature  of  the  subject,  the  statement  is  made  that  drainage 
was  employed  and  38  per  cent,  of  these  cases  died;  whereas  in  forty-one  cases,  i.  e., 
80  per  cent.,  of  those  in  which  drainage  was  not  employed  or  was  not  mentioned, 
death  occurred.  The  injured  pancreatic  tissue  has  been  turned  in  and  the  opposed 
pancreatic  peritoneal  surfaces  have  been  brought  together  with  deep  sutures  in 
order  to  prevent  leakage  of  pancreatic  juice,  but  when  necrosis  of  the  sutured  tissue 
results,  this  object  is  defeated. 

The  relation  of  diabetes  mellitus  to  the  pancreas,  first  demonstrated  by  the  ex- 
periments of  von  ]\Iering  and  Minkowski,  is  of  special  interest  to  the  surgeon  for 
two  reasons:  (1)  the  presence  of  diabetes  mellitus  caused  by  lesions  of  the  pancreas, 
such  as  gangrenous  pancreatitis  or  a  cyst,  may  affect  the  result  of  operations  under- 
taken for  these  conditions;    (2)  when  a  part  of  the  gland  is  removed  at  operation, 

'  Doberauer,  G.:  "Ueber  die  sogenannte  akute  Pankreatitis,"  Beit.  z.  klin.  Chir.,  19C6, 
xlviii,  456. 

VOL.  II — 36 


562  SURGERY  OF  THE  PANCREAS. 

diabetes  may  follow,  because  the  part  which  remains  is  insufficient  to  accomplish 
the  normal  function  of  the  gland. 

The  occurrence  of  glycosuria  in  association  with  pancreatic  disease  indicates 
that  the  lesion  is  far  advanced  and  implicates  almost  the  entire  gland.  The  prog- 
nosis in  such  cases  is  grave.  The  tendency  to  infection  is  increased  when  diabetes 
complicates  operations  performed  upon  the  diseased  gland,  but  not  infrequently 
operative  interference  offers  the  only  possibility  of  benefit  and  should  be  undertaken. 
A  patient  of  Gessner  ^  with  diabetes  lived  five  months  after  an  operation  for  gan- 
grenous pancreatitis.  Diabetes  is  usually  a  terminal  event,  and  a  case  of  Riegner^ 
is  exceptional,  because  slight  glycosuria  disappeared  after  operation. 

When  operation  is  performed  upon  the  gland,  preservation  of  as  much  pancreatic 
tissue  as  possible  is  of  great  importance.  Experiments  of  Minkowski^  showed  that 
when  a  fourth  or  a  fifth  of  the  gland  remained  in  dogs  glycosuria  failed  to  appear; 
if,  however,  only  an  eighth  or  a  twelfth  remained,  alimentary  glycosuria  appeared. 
The  limit  of  functional  sufficiency  in  man  is  not  defined,  and  particularly  when 
the  gland  is  the  seat  of  disease  it  may  readily  be  encroached  upon.  In  a  case  of 
Zweifel*  the  entire  pancreas  save  a  part  of  the  head,  three  centimeters  in  length, 
was  resected;  glycosuria  appeared  after  operation.  In  some  instances  diabetes  has 
followed  weeks  or  even  months  after  operation,  and  has  doubtless  been  the  result 
of  a  progressive  lesion  of  the  gland.  Occlusion  of  the  pancreatic  duct  does  not 
cause  glycosuria,  but  produces  chronic  interstitial  inflammation  of  that  part  of  the 
gland  which  is  drained  by  the  occluded  duct,  with  the  formation  of  dense,  scar-like, 
connective  tissue.  The  histologic  structures  known  as  islands  of  Langerhans,  at 
first  spared  by  the  lesion,  are  finally  implicated,  and  diabetes  results.  Especially 
when  the  head  of  the  gland  is  the  seat  of  operation,  injury  or  occlusion  of  the  duct 
of  Wirsung  must  be  avoided. 

FAT  NECROSIS. 

The  occurrence  of  characteristic  foci  of  fat  necrosis  distributed  in  the  fat  of  the 
omentum  and  mesentery  not  infrequently  offers  to  the  surgeon  who  has  opened  the 
abdomen  the  first  suggestion  of  the  existence  of  pancreatic  disease.  The  lesion 
was  first  adequately  described  by  Balser  ^  as  an  often  fatal  disease  causing  seques- 
tration and  necrosis  of  the  pancreas.  The  somewhat  indefinite  symptoms  which 
have  been  ascribed  to  it  are  those  of  the  primary  disease  of  which  it  is  a  conse- 
quence in  much  the  same  way  that  jaundice  is  the  result  of  various  diseases  of  the 
fiver. 

Foci  of  fat  necrosis  occur  in  the  fat  about  the  pancreas,  in  the  omentum,  in  the 

'  Gessner:     "Ueber  Pankreasnekrose,"  Deutsche  Zeit.  f.  Chir.,  1899,  xliv,  65. 

^  Riegner,  O.:  "  Zur  Diagnose  und  Operation  der  Pankreascysten,"  Berliner  klin.  Woch., 
1890,  xxvii,  957. 

^Minkowski,  O.:  "Ueber  den  Diabetes  mellitus  nach  Exstirpation  des  Pankreas,"  Arch, 
f.  exper.  Path.  u.  Phar.,  1893,  xxxi,  85. 

^  Zweifel,  P.:  "Exstirpation  einer  Pankreascyste,  Heilung  der  Kranken,"  Cent.  f.  Gynak., 
1894,  xviii,  641. 

5  Balser:     "Ueber  Fettnekrose,"  Virchow's  Arch.,  1882,  xc,  520. 


FAT    NECROSIS.  563 

mesentery,  and  in  the  fat  in  other  situations,  as  sharply  defined,  opaque  white  or 
yellowish  areas  in  sharp  contrast  to  the  translucent  fat  in  which  they  are  embedded; 
they  are  often  surrounded  by  a  narrow  hemorrhagic  zone.  They  are  usually 
rounded  in  shape  and  vary  from  minute  points  to  patches  half  a  centimeter  or  more 
in  diameter,  and  are  distinguishable  from  caseous  tubercles  or  from  metastases  of 
carcinoma  by  the  absence  of  elevation  due  to  the  presence  of  newly  formed  tissue; 
they  give  the  impression  that  fat  itself  has  undergone  transformation. 

Such  foci  occur  in  greatest  abundance  about  the  pancreas,  where  they  may  be 
confluent.  They  may  be  widely  distributed  throughout  the  abdomen,  occurring 
in  the  fat  below  both  the  visceral  and  parietal  peritoneum.  Fat  necrosis,  when 
widely  distributed  in  the  abdomen,  occurs  in  rare  instances  below  the  pleura  and 
pericardium  and  even  in  the  subcutaneous  fat,  causing  in  one  instance  localized 
injection  of  the  overlying  skin  noticed  during  life  (Hansemann^). 

Pathogenesis. — Histologic  studies  of  R.  Langerhans^  have  shown  that  the  fat 
of  the  necrotic  cell  is  split  into  fatty  acid,  which  is  deposited  in  crystaUine  form, 
and  glycerin,  which  undergoes  absorption.  The  lesion  may  be  produced  in  animals 
by  the  injection  of  emulsions  of  pancreatic  tissue,  whereas  a  variety  of  injuries 
which  allow  the  escape  of  pancreatic  juice  into  the  tissues  about  the  gland  are 
followed  by  appearance  of  fat  necroses  (Hildebrand^  and  Dettmer^  and  others). 
These  facts  have  suggested  the  probability  that  the  lesion  is  caused  by  pene- 
tration of  the  fat-splitting  enzyme  of  the  pancreatic  juice,  perhaps  aided  in  its 
action  by  trypsin,  about  the  pancreas;  Flexner  has  demonstrated  the  presence 
of  steapsin.  If  the  pancreatic  ducts  of  the  cat  are  ligated,  widespread  necrosis  of 
almost  the  entire  abdominal  fat  results  within  about  four  weeks;  if  after  duct- 
ligation  pilocarpin,  which  stimulates  secretion  of  pancreatic  juice,  is  administered, 
death  occurs  with  equally  widespread  fat  necrosis  at  the  end  of  several  days  (Opie^). 
Fat  necrosis  caused  by  the  escape  of  pancreatic  juice  into  the  tissues  about  the  pan- 
creas is  a  manifestation  of  pancreatic  disease  in  the  same  way  that  bile-staining  of 
tissue  indicates  biliary  obstruction. 

Surgical  Significance. ^In  man  fat  necrosis  more  frequently  accompanies 
hemorrhagic  and  gangrenous  pancreatitis  than  other  lesions  of  the  gland,  and  when 
widespread  indicates  with  few  exceptions  the  presence  of  this  disease.  Suppurative 
pancreatitis  is  less  frequently  followed  by  the  lesion.  Fat  necrosis  may  accompany 
obstruction  of  the  pancreatic  ducts  caused  by  gall-stones,  carcinoma,  or  other  cause, 
but  in  such  cases  the  lesion  is  usually  limited  to  the  tissues  about  the  pancreas. 

Characteristic  foci  of  fat  necrosis  are  recognized  when  the  abdomen  has  been 
opened  for  the  purpose  of  exploration  or  when  acute  hemorrhagic  pancreatitis  has 

'  Hansemann:     Discussion — Berliner  klin.  Woch.,  1889,  xxvi,  1115. 

^  Langerhans,  R. :     "Ueber  multiple  Fettgewebsnekrose,"  Virchow's  Arch.,  1890,  cxxii,  252. 
^  Hildebrand:     "Ueber  Experimente  zur  Erzeugung  von  Fettnekrosen,"  Cent.  f.  Chir.,  1895, 
xxii,  297. 

*  Dettmer:     "Die  Fettgewebsnekrosen,"  Inaug.  Diss.  Gottingen,  1895. 

^  Opie,  Eugene  L.:  "Contributions  to  the  Science  of  Medicine.  Dedicated  to  Wm.  H. 
Welch,"  Johns  Hopkins  Hospital  Reports,  1900,  ix,  859. 


564  SURGERY  OF  THE  PANCREAS. 

caused  a  mistaken  diagnosis  of  intestinal  obstruction,  and  may  give  the  first  indica- 
tion of  disease  of  the  pancreas.  That  the  lesion  may  disappear  is  shown  by  cases  in 
which  fat  necrosis  observed  at  operation  has  been  absent  at  a  second  operation 
undertaken  several  months  later. 


ACUTE  HEMORRHAGIC  PANCREATITIS. 

The  lesion  known  as  acute  hemorrhagic  pancreatitis,  which  is  characterized  by 
widespread  necrosis  of  the  pancreatic  tissue  and  by  hemorrhage  into  and  about  the 
gland,  has  little  analogy  among  diseases  of  other  organs,  for  the  reason  that  its 
occurrence  is  dependent  upon  the  peculiar  physiology  of  the  pancreas.  So-called 
gangrenous  pancreatitis  represents  a  late  stage  of  the  hemorrhagic  lesion;  hemor- 
rhagic and  necrotic  tissue  undergoes  changes  probably  due  both  to  the  pancreatic 
enzymes  and  to  invading  bacteria  and  assumes  an  appearance  usually  described  as 
gangrenous.  Bacteria  invading  from  the  duodenum  may  cause  suppuration,  which 
usually  extends  to  the  lesser  peritoneal  cavity,  but  the  hemorrhagic  and  gangrenous 
lesion  is  distinguishable  both  in  origin  and  in  its  subsequent  course  from  primary 
suppurative  pancreatitis,  which  does  not  materially  differ  from  abscess  of  other 
organs.  This  distinction  was  first  pointed  out  by  Fitz,^  and  has  been  neglected  by 
those  who  for  convenience  of  clinical  grouping  classify  all  pancreatic  inflammation 
as  acute,  subacute  {e.  g.,  gangrenous  pancreatitis),  and  chronic. 

The  occurrence  of  hemorrhage  into  the  pancreas,  or  pancreatic  apoplexy, 
analogous  to  cerebral  apoplexy,  has  been  much  discussed;  such  hemorrhage  has 
some  medicolegal  interest,  since  it  has  been  believed  to  be  a  cause  of  sudden  death. 
Hemorrhage  caused  by  traumatism  or  by  malignant  growth  presents  nothing  pe- 
culiar to  the  organ.  Recent  literature  contains  no  well  described  cases  of  so-called 
pancreatic  apoplexy,  and  increased  knowledge  of  the  etiology  and  pathogenesis 
of  acute  hemorrhagic  pancreatitis  have  furnished  evidence  that  necrosis  of  the  pan- 
creatic parenchyma  and  of  blood-vessels,  hemorrhage,  and  inflammatory  changes 
occur  side  by  side.  Acute  hemorrhagic  and  gangrenous  pancreatitis  will  be  des- 
cribed as  one  disease,  since  the  gangrenous  lesion  represents  a  late  stage  of  the 
former. 

Etiology. — Acute  hemorrhagic  pancreatitis  occurs  more  frequently  in  men  than 
in  women,  the  proportion  being  about  two  to  one;  with  few  exceptions  the  disease 
occurs  between  the  ages  of  twenty  and  fifty  years.  Individuals  in  good  health  are 
occasionally  attacked  by  the  disease;  obesity  is  believed  to  favor  its  occurrence. 
In  about  half  the  cases  the  disease  is  preceded  by  attacks  of  indigestion  accompanied 
by  pain  referred  to  the  stomach  or  attributed  to  biliary  colic.  In  some  instances 
there  has  been  evidence  of  gastroduodenitis,  but  it  is  not  improbable  that  this  con- 
dition is  secondary  to  the  pancreatic  lesion. 

Acute  hemorrhagic  pancreatitis  characterized  by  necrosis  of  tissue  with  hemor- 
rhage, and  accompanied  by  disseminated  fat  necrosis,  has  been  reproduced  in 

1  Fitz,  R.  H.:     "Acute  Pancreatitis,"  Med.  Record,  1889,  xxxv,  197,  225,  253. 


ACUTE   HEMORRHAGIC    PANCREATITIS.  565 

animals  by  the  injection  into  the  pancreatic  duct  of  a  variety  of  substances,  such 
as  acids  and  alkahes,  bacterial  cultures,  etc.,  all  of  which  act  as  irritants  and  injure 
the  secreting  parenchyma  of  the  gland.  It  is  not  improbable  that  the  enzymes  of 
the  pancreas,  particularly  trypsin,  acting  upon  tissues  injured  by  the  irritant,  have 
an  important  part  in  the  pathogenesis  of  the  lesion.  Hlava  has  shown  that  arti- 
ficial gastric  juice  injected  into  the  duct  causes  the  lesion  in  animals. 

The  frequent  association  of  cholelithiasis  with  acute  hemorrhagic  pancreatitis 
has  directed  attention  to  the  close  relation  which  exists  between  the  biliary  and  the 
pancreatic  ducts;  Opie^  in  1901  collected  from  the  hterature  thirty-two  cases  of 
acute  pancreatitis  with  gall-stones  in  eight  instances  impacted  in  the  lower  part  of 
the  common  bile-duct.  A  case  observed  later  disclosed  a  mechanism  which  has 
explained  this  association.  In  an  individual  who  died  nine  days  after  the  onset  of 
acute  hemorrhagic  pancreatitis  a  small  gall-stone  was  found  at  the  orifice  of  the 
diverticulum  of  Vater.  The  calculus,  being  of  small  size,  only  partially  filled  the 
diverticulum,  so  that  the  common  bile-duct  was  made  continuous  with  the  duct  of 
Wirsung,  which  was  stained  with  bile.  Experiments  upon  dogs  showed  that  bile 
injected  into  the  pancreatic  duct  caused  acute  hemorrhagic  pancreatitis  with  fat 
necrosis.    Bunting^  has  recently  observed  a  case  almost  identical  with  that  just  cited. 

A  small  number  of  cases  show  that  acute  hemorrhagic  and  gangrenous  pancrea- 
titis may  follow  traumatism,  such  as  the  kick  of  a  horse,  in  the  epigastric  region 
(Selberg^).  Mechanical  injury  to  the  tissue  of  the  gland,  perhaps  with  thrombosis 
and  occlusion  of  blood-vessels,  acting  in  association  with  the  enzymes  of  the  gland 
may  be  responsible  for  the  lesion. 

Experiments  of  Guleke*  and  of  Doberauer  indicate  that  symptoms  of  the 
disease  are  referable  to  toxic  products  of  the  altered  or  necrotic  glandular  tissue,  and 
Egdahl^  has  recently  furnished  evidence  that  products  of  pancreatic  autolysis  de- 
pressing blood-pressure  may  have  considerable  toxicity. 

Stage  of  Hemorrhage. — Sudden  onset  is  a  feature  of  most  cases  of  the  disease; 
there  is  intense  epigastric  pain  in  an  individual  who  has  perhaps  suffered  with  pre- 
vious attacks  of  abdominal  pain  referred  to  the  stomach  or  to  biliary  colic.  In  a 
smaller  number  of  instances  the  disease  attacks  individuals  who  have  previously 
enjoyed  good  health.  Pain  is  localized  above  the  umbilicus  perhaps  to  the  left 
of  the  mid-line,  and  is  usually  of  great  severity.  Pain  is  accompanied  by  vomiting, 
which  may  recur  at  short  intervals.  Symptoms  of  shock  accompany  the  pain  and 
vomiting.  There  is  profound  weakness  and  depression  of  circulation  with  acceler- 
ated pulse  and  in  some  instances  cyanosis. 

^  Opie,  Eugene  L.:  "Cholelithiasis  and  Disease  of  the  Pancreas,"  Amer.  Jour,  of  the  Med. 
Sciences,  1901,  cxxi,  27.     Bull,  of  the  Johns  Hopkins  Hospital,  1901,  xii,  182. 

2  Bunting,  C.  H.:  "A  Case  of  Acute  Hsemorrhagic  Pancreatitis,"  Bull,  of  the  Johns  Hopkins 
Hospital,  1906,  xvii,  265. 

^  Selberg:     "Traumatische  Pankreasnekrose,"  Berliner  kiln.  Woch.,  1901,  xxxviii,  923. 

^  Guleke,  N.:  "Ueber  die  experimentelle  Pankreasnekrose,"  Arbeit  a.  d.  chir.  Klin.  d. 
Konig.  Univ.  Berlin,  1906,  xviii,  368. 

^Egdahl:  "Intravenous  Injections  of  Pancreatic  Tissue,"  Jour,  of  Exper.  Med.,  1907,  ix, 
385. 


566  SURGERY  OF  THE  PAXCREAS. 

The  abdomen  is  rigid  and  tender  and  often  distended,  especially  in  the  epigastric 
region;  a  tumor  is  rarelv,  if  ever,  palpable.  In  approximately  one-half  of  the 
cases  there  is  constipation,  which  is  often  relieved  spontaneously  or  as  the  result 
of  enemata  about  the  fourth  day  of  the  attack.  The  stools  may  be  clay-colored 
and  jaundice  has  been  present  in  a  considerable  proportion  of  cases.  -  Fever  is 
rarely  present  until  secondary  changes  have  occurred  in  the  diseased  gland. 
Leukocytosis  has  been  found.  Acute  hemorrhagic  pancreatitis  is  not  commonly 
accompanied  by  glycosuria  because  the  disease  rarely  affects  the  entire  gland. 

With  severe  collapse  death  occasionally  occurs  within  twenty-four  hours;  a 
large  proportion  of  cases  are  fatal  within  four  or  five  days,  and  the  pancreas  presents 
the  typical  lesion  of  acute  hemorrhagic  pancreatitis;  the  gland  is  enlarged  and  in 
sharply  defined  areas  the  tissue  has  assumed  a  dark  red,  often  reddish-black  color; 
hemorrhage  has  occurred  in  and  about  the  gland,  the  lesser  peritoneal  ca'^'ity  often 
containing  blood-stained  fluid.  ^licroscopic  examination  shows  that  the  affected 
tissue  has  undergone  complete  necrosis,  destroying  the  glandular  parenchvma, 
interstitial  tissue,  and  blood-vessels.  There  is  e^^idence  of  inflammatory  reaction, 
especially  at  the  margin  of  the  necrotic  areas.  About  the  pancreas  and  often 
widely  disseminated  throughout  the  abdominal  canity  are  conspicuous  foci  of  fat 
necrosis. 

Stage  of  Gangrene. — In  about  one-half  of  the  cases  the  disease,  often  less 
severe  in  onset,  pursues  a  more  chronic  course,  lasting  weeks  or  even  months.  In 
such  cases  the  necrotic  and  hemorrhagic  tissue  becomes  soft,  black,  and  gangrenous 
in  appearance.  Infection  of  the  injured  tissue  is  followed  by  suppuration  witliin 
and  about  the  gland,  which  occasionally  undergoes  complete  sec|uestration.  Ac- 
cumulation of  purulent  fluid  containing  necrotic  tissue  and  partially  disintegrated 
fat  is  a  constant  result  of  so-called  gangrenous  pancreatitis. 

The  violent  symptoms  which  occur  with  the  onset  of  acute  hemorrhagic  pan- 
creatitis diminish  in  intensity;  pain  in  the  epigastrium  persists  and  may  be  accom- 
panied by  vomiting.  The  transition  from  so-called  hemorrhagic  to  gangrenous 
pancreatitis  usually  occurs  during  the  second  week,  and  is  indicated  by  s}Tnptoms 
of  inflammation  within  the  lesser  peritoneal  ca^'ity.  The  temperature  is  elevated, 
reaching  perhaps  104°  F.,  and  there  may  be  chills,  though  occasionally  there  is  no 
fever.  There  is  leukocytosis.  A  tumor  referable  to  accinnulation  of  exudate  in 
the  lesser  peritoneal  ca^^ ty  is  usually  present  in  the  epigastric  region,  extending 
toward  the  spleen,  but  is,  as  a  rule,  ill-defined  and  varies  much  in  size.  In  some 
cases  suppuration  within  the  lesser  peritoneal  cavity  causes  erosion  of  the  tissue 
over  the  left  kidney  and  swelling  below  the  left  costal  margin  in  the  back.  Fatty 
stools  and  glycosuria  are  rarely  present  to  suggest  pancreatic  disease.  Jaundice 
occurs  in  about  a  fifth  of  the  cases. 

Diagnosis. — Acute  hemorrhagic  pancreatitis,  when  accompanied  at  the  onset 
by  constipation,  is  frequently  mistaken  for  intestinal  obstruction  and  operation  has 
been  undertaken  repeatedly  for  the  relief  of  this  condition.  The  severity  of  pain 
and  its  localization  in  the  epigastrium,  together  with  the  intensity  of  collapse,  may 


SUPPURATIVE  PANCREATITIS.  567 

suggest  pancreatic  disease;  the  stercoraceous  vomiting  and  the  visible  peristalsis 
of  intestinal  obstruction  are  absent. 

The  frequent  association  of  gall-stone  colic  with  acute  pancreatitis  increases  the 
difficulties  of  differential  diagnosis.  Intensity  of  pain  in  the  epigastric  region,  per- 
haps to  the  left  of  the  median  line,  in  association  with  profound  collapse  may  point 
to  disease  of  the  pancreas  in  an  individual  who  has  suffered  with  attacks  of  typical 
biliary  colic. 

Several  weeks  after  the  onset  of  symptoms  a  palpable  tumor  situated  between 
the  stomach  and  colon  suggests  the  presence  of  exudate  within  the  lesser  peritoneal 
ca^^ty  and  indicates  pancreatic  gangrene,  if  there  is  a  history  of  the  acute  onset 
pre\aously  mentioned. 

SUPPURATIVE  PANCREATITIS. 

Abscess  of  the  pancreas,  unlike  hemorrhagic  pancreatitis,  presents  little  that 
is  peculiar  to  the  gland,  and  may  be  the  result  of  bacterial  invasion  from  the  duo- 
denum by  way  of  the  pancreatic  duct,  of  extension  from  an  adjacent  organ  or,  very 
rarely,  of  generalized  pyemia  by  way  of  the  blood-vessels.  The  normal  pancreatic 
duet  is  well  protected  from  entrance  of  duodenal  contents,  but  obstruction  of  the 
duct  by  carcinoma,  by  pancreatic  calculi,  or  ])y  gall-stones,  often  associated  with 
inflammation  of  the  bile-passages,  may  favor  the  entrance  of  pyogenic  micro-organ- 
isms and  cause  suppuration.  Ascending  infection  of  the  unobstructed  duct 
doubtless  occurs.  Suppuration  may  produce  a  localized  abscess  or  may  affect 
diffusely  the  entire  gland.  Fitz  pointed  out  that  suppurative  pancreatitis  is  ac- 
companied by  fat  necrosis  less  frequently  than  hemorrhagic  and  gangrenous  pan- 
creatitis. 

The  necrotic  and  hemorrhagic  tissue  which  is  present  with  acute  hemorrhagic 
pancreatitis  is  especially  susceptible  to  bacterial  invasion,  and  suppuration  both  of 
the  diseased  pancreas  and  of  the  overlying  lesser  peritoneal  ca\dty  occurs.  In  some 
instances  it  is  impossible  to  determine  at  operation,  or  even  at  avitopsy,  if  abscess 
formation  has  been  preceded  by  hemorrhagic  pancreatitis. 

Symptoms. — In  about  cne-half  of  the  instances  of  suppurative  pancreatitis 
the  onset  occurs  with  intense  vomiting,  pain,  and  profound  collapse  suggesting 
hemorrhagic  inflammation  of  the  gland.  The  symptoms  diminish  in  severity  and 
the  disease  tends  to  pursue  a  chronic  course,  often  lasting  several  months.  In  a 
somewhat  smaller  group  of  cases  the  onset  is  gradual;  there  is  epigastric  pain  or 
perhaps  ill-defined  discomfort,  together  with  symptoms  referred  to  as  indigestion. 
Symptoms  which  give  evidence  of  suppuration  are  fever,  leukocytosis,  and  an  epi- 
gastric tumor.  Elevation  of  temperature  is  usually  moderate,  and  occasionally 
the  temperature  has  been  normal  or  subnormal,  and  there  has  been  little  to  suggest 
suppuration. 

The  presence  of  a  tumor  mass  between  the  stomach  and  the  colon,  definable 
often  with  difficulty,  gives  the  first  indication  for  operation,  which  alone  offers  an 
opportunity  for  recovery.     A  palpable  tumor  is  caused  by  accumulation  of  purulent 


568  SURGERY  OF  THE  PANCREAS. 

fluid  in  the  lesser  peritoneal  cavity,  wliich  almost  invariably  occurs  as  the  result  of 
pancreatic  suppuration.  Other  sequelae  are  thrombosis  of  the  portal  and  splenic 
veins,  abscess  of  the  liver,  perforation  into  stomach  or  intestine,  and  general 
peritonitis. 

CHRONIC  INTERSTITIAL  PANCREATITIS. 

Chronic  interstitial  pancreatitis  is  not  an  uncommon  disease,  but  is  rarely  ac- 
companied by  symptoms  wliich  make  its  recognition  possible  during  life. 

Etiology. — The  disease  is  somewhat  more  frequent  in  men  than  in  women,  and, 
like  hepatic  cirrhosis,  is  a  disease  of  middle  life,  occurring  usually  after  the  age  of 
forty  years.  Ligation  of  the  pancreatic  ducts  in  animals  is  followed  by  chronic  pan- 
creatitis, and  in  a  large  proportion  of  the  human  cases  chronic  inflammation  of  the 
gland  is  the  result  of  duct  obstruction  caused  by  carcinoma  or  a  cyst  compressing 
the  duct,  by  pancreatic  calculi  within  the  duct  of  Wirsung,  or  by  biliary  calculi  oc- 
cupying the  lower  part  of  the  common  bile-duct,  where  it  comes  into  contact  with 
the  main  duct  of  the  pancreas.  Riedel  ^  first  directed  attention  to  induration  of  the 
head  of  the  pancreas  observed  at  operations  undertaken  for  the  removal  of  gall- 
stones, and  showed  that  it  is  caused  by  chronic  inflammation  of  the  gland.  A  small 
calculus  lodged  in  the  diverticulum  of  Vater  may  divert  bile  into  the  pancreatic 
duct  and  cause  acute  hemorrhagic  pancreatitis,  but  a  large  calculus  in  the  same 
situation  occluding  the  duct  of  Wirsung  causes  chronic  inflammation. 

Pathology. — Chronic  pancreatitis  which  has  its  origin  in  changes  witliin  the 
ducts  tends  to  destroy  the  secreting  parenchyma  of  the  gland  and  is  associated  with 
an  increase  of  tissue  between  the  lobules.  A  second  type  of  chronic  inflammation, 
of  wliich  the  etiology  is  not  readily  defined,  afl^ects  the  tissue  more  diffusely,  so  that 
individual  acini  are  separated  by  newly  formed  interstitial  tissue.  Histologic 
studies  have  served  to  indicate  what  type  of  chronic  pancreatitis  is  accompanied  by 
diabetes  mellitus.  With  the  interacinar  lesion  which  invades  the  peculiar  structures 
known  as  islands  of  Langerhans  glycosuria  is  present,  but  with  the  interlobular 
type  which  tends  to  spare  these  bodies  glycosuria  occurs  only  when  the  lesion  is  far 
advanced.  Hence  diabetes  mellitus  accompanies  carcinoma  compressing  the  pan- 
creatic duct  and  pancreatic  calculi  only  when  the  resultant  chronic  interlobular 
pancreatitis  is  far  advanced. 

Surgical  Significance. — Certain  indefinitely  definable  symptoms,  such  as  pain 
in  the  epigastric  and  mid-scapular  regions,  vomiting,  emaciation,  and  weakness, 
have  been  attributed  to  chronic  inflammation  of  the  gland,  but  they  do  not  make  its 
recognition  possible.  Of  considerable  significance  for  the  surgeon  is  the  frequent 
association  of  cholelithiasis  and  chronic  pancreatitis  with  induration  of  the  head 
of  the  pancreas,  which  observed  at  operation  has  not  infrecj[uently  been  mistaken 
for  carcinoma  and  has  suggested  a  grave  prognosis  not  verified  by  the  subsequent 
course  of  the  disease. 

1  Riedel:  "Ueber  entziindliche  vergrosserungen  des  Pankreaskopfes,"  Berliner  klin.  Woch., 
1896,  xxxiii,  1,  32. 


CYSTS.  569 

CYSTS. 

Cysts  of  the  pancreas  have  been  classified  as  (1)  true  cysts  derived  from  the 
duets  or  from  the  secreting  cells  of  the  gland  and  consequently  lined  by  epithelium; 
and  (2)  pseudocysts,  which  have  no  epithelium  and  are  limited  by  thickened  con- 
nective tissue.  Among  pseudocysts  which  may  be  formed  by  degeneration  and 
softening  of  pancreatic  tissue  have  been  included  a  variety  of  diverse  lesions;  such 
cysts,  derived  from  the  gland,  may  after  rupture  of  pancreatic  tissue  communicate 
with  the  lesser  peritoneal  cavity,  the  walls  of  which  undergo  thickening.  In  many 
instances,  particularly  when  cysts  have  been  observed  at  operation,  it  has  been 
impossible  to  determine  whether  accumulation  of  fluid  within  the  lesser  peritoneal 
cavity  has  had  its  origin  in  the  pancreas;  in  some  instances  encapsulated  blood 
or  inflammatory  exudate  within  the  bursa  omentalis  has  been  mistaken  for  a 
pancreatic  cyst. 

According  to  Korte,^  cysts  of  the  pancreas  may  occupy  a  variety  of  situations 
which  depend  upon  the  relation  of  difi^erent  parts  of  the  gland  to  surrounding  organs : 
(1)  In  most  instances  the  cyst  growing  forward  presents  upon  the  abdominal  wall 
between  the  stomach  and  colon,  being  covered  by  the  gastrocolic  omentum,  w^hich 
must  be  divided  at  operation.  Pseudocysts  arising  from  the  pancreas  and  occupy- 
ing the  lesser  peritoneal  cavity  after  closure  of  the  foramen  of  Winslow  have  this 
situation.  (2)  A  cyst  arising  from  the  upper  border  of  the  pancreas  may  push  its 
way  between  the  lesser  curvature  of  the  stomach,  which  is  pushed  downward,  and 
the  liver,  being  covered  by  the  much-stretched  gastrohepatic  omentum.  (3)  The 
cyst,  especially  when  it  is  situated  in  the  tail  of  the  pancreas,  may  grow  into  the  meso- 
colon, separating  its  layers.  If  the  cyst  distends  the  upper  layer  of  the  membrane, 
the  colon  is  pushed  downward  and  the  tumor  during  life  is  found  between  the  stom- 
ach and  the  colon;  if,  on  the  contrary,  the  lower  layer  is  distended,  the  transverse 
colon  may  be  found  along  its  upper  border. 

Etiology  and  Pathology. — Pancreatic  cyst  is  about  equally  frequent  in  men 
and  in  women,  and  in  the  greater  number  of  cases  occurs  between  the  ages  of  twenty 
and  forty  years.  Retention  cysts  due  to  occlusion  of  ducts  are  usually  of  small  size 
and  are  unaccompanied  by  distinctive  symptoms;  such  cysts  have  been  described 
by  Virchow  as  ranula  pancreatica,  and  when  of  small  size  and  multiple,  by  Klebs  as 
acne  pancreatica.  Cysts  of  large  size  have  been  associated  with  pancreatic  calculi 
and  have  been  perhaps  due  to  obstruction  of  the  pancreatic  duct  by  an  impacted 
calculus. 

The  occurrence  of  multilobular  cysts  and  the  presence  of  papillary  projections 
upon  the  inner  surface  of  cysts  have  afforded  evidence  that  such  cysts  resemble 
tumors,  being  formed  by  proliferation  of  epithelial  cells  (proliferation  cysts).  In 
many  of  these  cases  the  nature  of  the  cyst  is  doubtful,  but  in  a  few  instances  the 
new-growth  resembles  the  cystadenomata  of  the  ovary  and  contains  papillary  in- 
growths. 

^  Korte,  W.:    "Pankreaserkrankungen,"  Deutsche  Chirurgie,  Stuttgart,  1898. 


570  SUEGERY  OF  THE  PAXCREAS. 

Witli  many  cysts  of  the  pancreas  there  is  a  history  of  trauma,  often  preceding 
immediately  the  appearance  of  an  abdominal  tumor;  forty-one  cases  are  cited  by 
Lazarus.  Nevertheless  the  presence  of  blood  frequently  found  in  pancreatic  cysts 
does  not  give  evidence  of  such  origin,  since  hemorrhage  may  occur  after  cyst-form- 
ation. There  is,  however,  abundant  e\adence  that  pseudocysts  may  occur  both  as 
the  result  of  traumatism  in  the  region  of  the  pancreas  and  of  acute  hemorrhagic 
pancreatitis.  In  both  instances,  doubtless,  necrosis  and  softening  of  tissue  are 
fohowed  by  accumulation  of  fluid;  blood  may  disappear  from  the  contents  of  these 
cysts. 

The  presence  in  cystic  contents  of  one  or  more  enzymes  resembling  those  of  the 
pancreas  was  formerly  believed  to  give  proof  that  a  cyst  had  its  origin  in  the  pan- 
creas. Not  infrequently  one,  or  perhaps  all,  of  these  enzymes  are  absent  in  the 
contents  of  a  pancreatic  cyst,  whereas  fat-splitting,  diastatic  or  proteolytic  enzymes 
are  found  in  fluids  not  derived  from  the  pancreas. 

Symptoms. — The  size  and  situation  of  the  tumor  caused  by  cysts  of  the  pan- 
creas are  so  variable  that  recognition  is  frequently  difficult.  A  rounded,  fluctuating 
tumor  in  the  epigastric  region  behind  the  stomach,  especially  when  in  large  part 
to  the  left  of  the  mid-line,  should  suggest  this  lesion.  The  tumor  is  often  the  size 
of  a  man's  head  and  is  usually  smooth  and  spherical,  but  may  distend  the  entire 
abdominal  cavity.  Occasionally  the  cyst  is  so  tense  that  it  appears  to  be  solid. 
Though  usually  fixed,  it  may  be  somewhat  movable,  especially  when  it  arises  from 
the  tail  of  the  gland. 

The  relation  of  the  tumor  to  the  stomach  and  colon  is  most  readily  determined 
after  inflation  of  these  organs.  The  stomach  usually  covers  small  cysts,  but  with 
increase  of  size  the  viscus  is  pushed  upward  and  its  tympany  separates  the  tumor 
from  the  hepatic  dullness.  The  colon  lying  along  the  lower  border  of  the  tumor 
may  be  pushed  dowmward  to  the  symphysis.  Cysts  presenting  alcove  the  stomach 
produce  dullness  in  contact  with  the  fiver,  the  stomach  lying  below  the  tumor. 
With  cysts  occupying  the  mesocolon  the  colon  may  be  found  above,  below,  or  across 
the  tumor. 

Disappearance  of  pancreatic  cysts  has  l)een  repeatedly  described.  In  some 
instances  it  follows  rupture  into  the  peritoneal  cavity;  in  several  cases  disappear- 
ance has  been  accompanied  by  temporary  diarrhea  of  a  character  which  has  sug- 
gested evacuation  into  the  intestine. 

Pain  and  other  symptoms,  namely,  indigestion  and  vomiting,  jaundice,  ascites, 
etc.,  are  referable  to  pressure  upon  adjacent  organs.  There  is  usually  weakness  and 
loss  of  weight.  Fatty  stools  due  to  occlusion  of  the  pancreatic  ducts  have  been 
associated  with  cyst  in  only  two  of  the  cases  collected  by  Fitz.^  Diabetes  has  been 
associated  with  cyst  in  few  cases,  and  indicates  that  destruction  of  the  pancreas  by 
resulting  chronic  inflammation  is  far  advanced. 

Diagnosis. — The  differential  diagnosis  of  pancreatic  cyst  is  at  times  difficult. 

'  Fitz,  R.  H.:  "The  Pancreas  and  Pancreatic  Diseases:  Symptomatologj'  and  Diagnosis." 
Trans,  of  the  Cong,  of  Amer.  Phys.  and  Surg.,  1903,  vi,  .36. 


CARCINOMA.  571 

Echinococcus  cyst  of  the  left  lobe  of  the  liver  may  be  mistaken  for  a  cyst  presenting 
above  the  abdomen;  the  stomach  when  distended  tends  to  cover  the  pancreatic, 
but  not  the  hepatic  cyst,  which  is  in  contact  with  the  abdominal  wall.  Cysts  of  the 
mesentery,  unless  fixed  by  adhesions,  are  found  near  the  umbilicus  and  are  freely 
movable;  cysts  of  the  mesocolon  are  indistinguishable  from  cysts  of  the  pancreas 
in  the  same  situation. 

Pancreatic  cysts  arising  from  the  tail  of  the  pancreas  and  situated  in  the  meso- 
colon may  lie  in  contact  with  the  pelvis  and  be  mistaken  for  ovarian  cysts;  large 
cysts  of  the  pancreas  filling  the  entire  abdomen  may  cause  the  same  error.  With 
pancreatic  cyst  there  is  a  history  of  epigastric  origin,  the  tumor  is  situated  behind 
the  stomach  and  colon,  and  the  uterus  is  not  dragged  upward,  the  ovaries  being 
perhaps  palpable. 

Puncture  of  pancreatic  cyst  for  purposes  of  diagnosis  is  inadvisable. 

CARCINOMA. 

Malignant  growth  primary  in  the  pancreas  occurs,  according  to  statistics  of 
Bashford,  once  among  sixty-four  instances  of  cancer  in  man  and  among  one  hun- 
dred and  seven  in  women.  Carcinoma  is  far  more  common  than  sarcoma.  Cancer 
usually  occurs  during  middle  life,  but  has  been  observed  as  early  as  two  years. 
The  tumor  is  usually  situated  in  the  head  of  the  gland,  which  has  been  affected 
eighty-two  times  among  one  hundred  and  thirteen  instances  of  primary  growth 
collected  by  Miraillie.^  The  entire  gland  may  be  implicated.  Since  the  pancreas 
is  frequently  invaded  by  carcinoma  of  the  stomach  and  occasionally  by  tumors  of 
the  duodenum  or  of  the  bile-passages,  the  origin  of  a  tumor  of  the  pancreas  may  be 
doubtful.  The  tumor  is  usually  hard  and  of  the  scirrhus  type,  but  cellular  or  en- 
cephaloid  cancers  occur.  Benign  adenomata  unassociated  with  cyst  formation 
have  been  described,  but  such  tumors  are  usually  of  small  size  and  have  little  clinical 
interest. 

Symptoms. — Pain  in  the  epigastrium  is  an  almost  constant  symptom  of  pan- 
creatic cancer,  but  varies  much  in  situation,  character,  and  intensity.  In  many 
instances  it  is  of  great  severity,  increasing  continuously  until  death,  whereas  it  may 
be  intermittent  or  colic-like.  The  deep-seated  tumor  mass  is  palpable  in  not  more 
than  a  fourth  of  the  cases;  it  is  usually  present  in  the  epigastrium,  but  may  be  felt 
in  the  right  or  in  the  left  hypogastrium.  The  mass  is  usually  immovable,  but  oc- 
casionally it  moves  with  respiration  or  transmits  aortic  pulsation. 

Symptoms  referable  to  the  stomach,  such  as  discomfort  after  eating,  nausea,  and 
vomiting  are  usually  present,  and  in  some  instances  compression  of  the  pylorus 
may  cause  dilatation  of  the  stomach.  Constipation  or  diarrhea  may  be  present; 
obstruction  of  the  intestine  may  be  the  result  of  pressure.  Jaundice  due  to  the  com- 
pression of  the  common  bile-duct  is  frequently  present,  since  the  tumor  is  usually 
situated  in  the  head  of  the  pancreas;   it  appears  suddenly  and  steadily  increases  in 

^Miraillie:     "Cancer  primitif  du  pancreas,"  Gaz.  des  hop.,  1893,  No.  94. 


572  SURGERY  OF  THE  PANCREAS. 

intensity.  Though  the  rule  suggested  by  Courvoisier^  is  not  without  exceptions, 
dilatation  of  the  gall-bladder  is  much  more  common  when  the  common  bile-duct 
is  obstructed  by  carcinoma  than  when  obstruction  is  due  to  cholehthiasis,  with 
which  there  is  usually  inflammatory  changes  causing  contraction.  The  liver, 
which  in  most  cases  fails  to  show  the  enlargement  which  accompanies  hepatic 
cancer,  may  be  enlarged  as  the  result  of  metastasis. 

Occlusion  of  the  pancreatic  duct  may  be  associated  with  digestive  disturbances 
due  to  lack  of  pancreatic  juice  in  the  intestine.  In  less  than  a  tenth  of  the 
cases  there  are  fatty  stools  or  impaired  digestion  of  meat  with  undigested  muscle 
fibers  in  the  feces.  Bulky  stools  suggest  pancreatic  disease  (Oser^).  Diabetes 
melhtus  accompanies  cancer  of  the  pancreas  in  a  considerable  proportion  of  cases, 
and  results  when  the  pancreas  is  in  large  part  destroyed  by  invasion  and  by  ad- 
vanced chronic  inflammation  due  to  occlusion  of  ducts;  Pearce  has  found  lesions 
of  the  islands  of  Langerhans. 

Diagnosis  of  cancer  of  the  pancreas  will  depend  upon  the  presence  of  jaundice 
appearing  gradually,  steadily  increasing,  and  attaining  great  intensity,  dilatation 
of  the  gall-bladder,  tumor  in  the  epigastric  region,  cachexia,  and  advanced  age. 
One  or  more  of  these  symptoms  may  be  absent,  but  without  jaundice  or  tumor  a 
diagnosis  is  scarcely  possible.  Symptoms  of  impaired  pancreatic  function,  namely, 
glycosuria  or  fatty  stools,  when  present,  confirm  the  diagnosis. 


PANCREATIC  CALCULUS. 

Pancreatic  hthiasis  is  an  uncommon  disease,  occurring  only  twice  among  fifteen 
hundred  autopsies  at  the  Johns  Hopkins  Hospital;  it  is  almost  five  times  as  frequent 
in  men  as  in  women,  and  occurs  usually  between  the  ages  of  thirty  and  fifty  years. 

Little  is  known  concerning  the  cause  of  calculus  formation  within  the  pancreatic 
ducts,  but  stagnation  of  secretion  and  bacterial  infection  of  the  pancreatic  ducts 
doubtless  afford  favorable  conditions,  for  calcuh  are  not  infrequently  found  within 
pancreatic  cysts,  and  biliary  and  pancreatic  lithiasis  in  a  considerable  proportion 
of  cases  are  associated. 

Pathology. — Pancreatic  stones  are  usually  multiple  and  vary  in  size  from  small 
sand-Uke  particles  to  masses  several  centimeters  in  diameter.  Chemical  examina- 
tion shows  the  presence  of  calcium  carbonate,  calcium  phosphate,  magnesium 
carbonate,  and  in  small  proportion  other  inorganic  salts,  together  with  a  small 
amount  of  organic  matter;  cholesterin  may  be  present.  The  absence  of  bile- 
pigment  and  of  bile-salts  may  give  indication  of  the  nature  of  a  calculus  passed  with 
the  feces. 

Occlusion  of  the  pancreatic  ducts  by  calculi  causes  chronic  interstitial  inflamma- 
tion of  the  gland,  which  is  interlobular  in  type  and  causes  diabetes  mehitus  only 
when  far  advanced. 

1  Courvoisier,  L.  G.:     Beit.  z.  Path.  u.  Chip,  der  Gallenwege,  Leipzig,  1890. 

2  Oser,  L.:    "Die  Erkrankungen  des  Paniireas,"  Nothnagel's  Spec.  Path.  u.  Ther.,  Wien,  1898. 


HISTORICAL.  573 

Abscess  due  to  suppuration  about  a  pancreatic  calculus  may  be  a  dangerous 
complication;  rupture  has  occurred  into  the  peritoneal  cavity  or  into  the  duodenum. 

Symptoms. — Stones  within  the  pancreatic  ducts  may  cause  no  symptoms.  Pain 
is  usually  present  and  may  be  continuous  or  intermittent.  Pancreatic  colic  analo- 
gous to  biliary  colic  occurs  during  the  passage  of  a  calculus,  but  is  an  inconstant 
feature  of  the  disease  and  is  scarcely  distinguishable  from  biliary  colic.  Jaundice 
may  be  caused  by  the  passage  of  a  calculus  through  the  diverticulum  of  Vater. 

Diagnosis. — Diagnosis  of  pancreatic  lithiasis  in  four  cases  collected  by  Kin- 
nicutt  ^  was  made  by  finding  in  the  feces  calculi  composed  of  calcium  carbonate 
or  phosphate  and  containing  no  bile-pigment  nor  other  constitutent  of  the  bile. 
Passage  of  such  calculi  may  follow  attacks  of  colic  referable  to  the  pancreas. 

Glycosuria  has  been  present  in  thirty-six  of  eighty  cases  of  pancreatic  lithiasis 
collected  by  Lazarus";  in  some  instances  alimentary  glycosuria  has  been  observed. 
Steatorrhea  was  present  in  ten  of  the  cases  of  I^azarus. 

When  calculi  are  not  discoverable  in  the  feces,  diagnosis  is  rarely  possible. 
In  a  case  of  Lichtheim^  colic  with  vomiting  was  unaccompanied  by  jaundice,  and 
the  presence  of  diabetes  mellitus  indicated  disease  of  the  pancreas. 


SURGICAL  TREATMENT  OF  DISEASES  OF  THE  PANCREAS. 
By  Stephen  H.  Watts,  M.D. 

Historical. — While  the  surgery  of  the  pancreas  has  hardly  kept  pace  with  our 
knowledge  of  its  pathology  and  physiology,  and  while  it  probably  remains  the  most 
incomplete  chapter  in  the  surgery  of  the  abdomen,  there  has  nevertheless  been  a 
gratifying  progress  in  the  operative  side  of  the  subject  in  recent  years.  The  tardy 
development  has  been  attributed  by  jNIikulicz*  to  the  topographic  relations  of  the 
organ,  the  difficulties  of  diagnosis,  and  the  dangers  of  operations  upon  it;  the  last 
being  due  to:  (a)  the  richness  of  its  blood-supply  and  the  consequent  difficulty  in 
controlling  hemorrhage;  (b)  to  the  discharge  of  pancreatic  secretion  with  the  pro- 
duction of  fat  necroses. 

Although  operations  upon  the  pancreas  had  been  previously  reported  by  Boze- 
man,  Kulenkampff,  Gussenbauer,  and  others,  the  surgery  of  the  pancreas  may  be 
said  to  date  from  the  work  of  Senn,^  which  was  published  in  1885.     An  extensive 

'Kinnicutt:  "Pancreatic  Lithiasis,  with  Report  of  a  Case."  Trans,  of  the  Assoc.  Amer. 
Phys.,  1902,  xvii,  80. 

^Lazarus:  Beitrag  zur  Pathologie  und  Therapie  der  Pankreaserkrankungen.  Berlin,  1904. 

^  Lichtheim:  "  Zur  Diagnose  der  Pankreasatrophie  durch  Rteinbildung."  Berliner  klin.  Woch.. 
1894,  Bd.  xxxi,  Nr.  8,  185. 

*  Mikulicz,  Joh.  von:  "Surgery  of  the  Pancreas,"  Transactions  of  the  Congress  of  American 
Physicians  and  Surgeons.  1903,  vi.  p.  55. 

"^  Senn,  Nicholas:  "The  Surgical  Treatment  of  Cysts  of  the  Pancreas."  Am.  Jour.  Med. 
Sci.,  1885,  xc,  17,  and  "Die  Chirurgie  des  Pankreas.  gestiitzt  auf  Versuche  und  klinische  Beobach- 
tungen,"  Volkmann's  Sammlung  klin.  Vortrage,  1886-1890,  Nr.  313. 


574  SURGICAL   TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 

review  of  the  subject  by  Nimier^  appeared  in  1893,  and  in  1898  a  great  impetus  was 
given  to  its  study  by  the  pubHcation  of  Korte's  splendid  monograph/  to  which  the 
reader  is  referred  for  a  complete  bibliography  to  that  date.  The  most  important 
contribution  in  recent  years  is  that  of  Mayo  Robson,^  to  whom  we  owe  in  a  great 
measure  our  understanding  of  chronic  pancreatitis. 

Surgical  Topography. — In  most  cases  the  pancreas  is  so  covered  by  the  liver, 
stomach,  duodenum,  and  transverse  colon  that  none  of  it  is  visible  when  the  ab- 
domen is  opened;  however,  in  certain  cases,  owing  to  variations  in  the  size  and 
position  of  these  organs,  more  or  less  of  the  pancreas  may  be  covered  merely  by  the 
gastrohepatic  or  gastrocolic  omentum.  The  size  of  the  stomach  varies  with  its 
state  of  fullness;  when  distended,  it  completely  covers  the  pancreas,  but  in  the  con- 
tracted condition  considerable  portions  of  the  pancreas  may  be  exposed.  When 
the  liver  is  small  and  the  stomach  is  contracted  or  in  descensus,  there  is  easy  access 
to  the  pancreas  above  the  lesser  curvature  of  the  stomach.  If  the  stomach  is  small 
and  the  transverse  colon  is  low,  a  large  part  of  the  pancreas  may  be  felt  through  the 
gastrocolic  omentum.  The  anatomic  relations  of  the  pancreas  are  well  shown  in 
Figs.  765,  766,  767. 

To  investigate  the  relations  of  the  neighboring  organs  to  the  pancreas,  with 
especial  reference  to  the  organs  which  cover  it,  Korte*  examined  thirty  bodies  of 
persons  over  six  years  of  age,  the  majority  being  those  of  adults.  It  was  found  that 
in  twenty  bodies  the  pancreas  was  completely  covered,  usually  by  the  projecting  edge 
of  the  Kver  and  the  distended  transverse  colon  lying  next  to  it,  rarely  by  the  dilated 
stomach.  In  ten  bodies  the  pancreas  was  in  places  covered  only  by  the  omentum; 
in  fact,  in  six  of  these  the  head  of  the  gland  was  directly  accessible  between  the  edge 
of  the  liver  and  the  low-lying  transverse  colon.  In  the  same  material  he  examined 
the  mobility  of  the  organ:  in  two  a  slight  amount  of  motion  was  possible  in  the  tail 
of  the  pancreas;  in  forty-eight  it  was  firmly  fixed  in  the  retroperitoneal  tissues. 

The  pancreas  may  be  attacked  transperitoneally  or  extraperitoneally.  The 
methods  of  approach  may  be  thus  classified : 

1.  Transperitoneal  methods. 

(a)  Through  the  gastrohepatic  omentum. 
(h)  Through  the  gastrocoKc  omentum. 
(c)   Through  the  transverse  mesocolon. 

2.  Extraperitoneal  methods. 

(a)  Lateral  abdominal. 

(b)  Tumbar. 

The  approach  through  the  gastrohepatic  omentum,  which  is  unusual  and  chiefly 

iNimier,  H.:  "Notes  sur  la  Chirurgie  du  Pancreas,"  Revue  de  Chirurgie,  1893,  xiii,  617, 
and  xiv,  584. 

=>  Korte,  W.:  "Die  chirurgischen  Krankheiten  und  die  Verletzungen  des  Pankreas,"  Deut- 
sche Chirurgie,  1898,  45,  b  and  d. 

^Robson,  A.  W.  Mayo:  "Pancreatitis,  with  Especial  Reference  to  Chronic  Pancreatitis," 
Lancet,  1900',  ii,  235. 

*  Korte:  Loc.  cit. 


DISPLACEMENTS   AND    PROLAPSE    OF   THE   PANCREAS.  575 

used  for  cysts  which  present  above  the  stomach,  is  much  simplified  if  the  Hver  is 
small.  The  usual  method,  and  that  which  exposes  the  entire  gland,  if  necessary,  is 
to  make  an  opening  in  the  gastrocolic  omentum,  which  lays  open  the  lesser  peritoneal 
cavity  (Fig.  766).  Another  method  of  approach  is  that  through  the  transverse 
mesocolon.  If  the  transverse  colon  and  omentum  are  lifted  up,  the  tail  of  the 
pancreas  can  be  seen  through  the  mesentery  of  the  colon  and  exposed  by  making 
an  opening  in  this  region.  The  left  colic  artery,  an  important  branch  of  the  inferior 
mesenteric  artery,  should  be  avoided. 

The  organ  can  also  be  reached,  without  opening  the  abdominal  cavity,  by  means 
of  the  lateral  abdominal  incision  of  Bardenheuer^  or  the  lumbar  incision  of  Robson.^ 
The  former  is  an  incision  extending  from  the  tip  of  the  twelfth  rib  to  a  line  joining  the 
anterior  superior  spine  and  the  umbilicus,  being  directed  downward  and  inward  to- 
ward the  mid-point  of  Poupart's  ligament.  The  incision  is  carried  down  through  the 
abdominal  muscles  to  the  subperitoneal  tissues,  the  lower  and  anterior  portion  of  the 
kidney  is  exposed,  and,  pushing  the  peritoneum  upward  and  inward,  a  good  ex- 
posure of  the  tail  and  body  of  the  pancreas  is  obtained  when  the  incision  is  on  the  left 
side.  The  exposure  of  the  head  of  the  pancreas  by  a  similar  incision  on  the  right 
side  is  not  very  satisfactory. 

The  pancreas  can  be  exposed  also  posteriorly  by  an  incision  in  the  costovertebral 
angle.  This  method  has  been  used  for  the  drainage  of  cysts  and  abscesses,  but  is 
not  to  be  recommended  when  a  good  exposure  of  the  organ  is  desired. 

Displacements  and  Prolapse  of  the  Pancreas. — Although  the  pancreas  is 
usually  firmly  fixed  in  position,  a  number  of  cases  are  on  record  where  it  had  a  con- 
siderable range  of  mobility.  Estes  and  Runge  have  reported  cases  in  which  the 
pancreas  formed  a  part  of  the  pedicle  of  a  wandering  spleen.  It  has  been  found 
in  diaphragmatic  and  umbilical  hernias.  Of  276  cases  of  diaphragmatic  hernia 
collected  by  Lacher,  in  twenty-seven  the  pancreas  formed  a  portion  of  the  hernial 
content.  Schmitt  and  Rettig  report  cases  in  which  it  was  present  in  congenital  um- 
bilical hernias  and  Rose  mentions  a  case  where  it  was  found  in  an  acquired  umbilical 
hernia.  In  the  case  of  Baud  the  pancreas  was  included  in  an  intestinal  intussus- 
ception. 

The  possibility  of  a  prolapse  of  the  pancreas  through  an  abdominal  wound  has 
been  disputed,  but  cases  are  recorded  which  prove  that  such  a  thing  may  occur. 
Korte  collected  eight  such  cases,  among  which  were  those  of  Kleberg,  Otis,  Dargan, 
and  others.  In  seven  cases  the  prolapsed  portion  was  excised  and  in  one  it  was  re- 
placed :  seven  recovered  and  one  died.  More  recently  Foy  and  Fontoynant  have 
reported  cases  in  which  the  prolapsed  portion  of  the  pancreas  was  replaced:  one 
case  recovered  and  one  died,  apparently  from  the  results  of  a  concomitant  wound  of 
the  stomach. 

The  proper  treatment  of  prolapse  of  the  pancreas  will  depend  upon  the  case. 
If  the  wound  is  recent  and  the  protruding  part  of  the  pancreas  is  in  good  condition, 

'  Bardenheuer,  B.:     "Der  extraperitoneale  Explorativschnitt,"  Stuttgart,  1887,  S.  216. 
2  Robson,  A.  W.  Mayo:     "Pancreatitis,"  Brit.  Med.  Jour.,  May  11,  1901,  i,  1129. 


576  SURGICAL   TREATMENT    OF   DISEASES    OF   THE   PANCREAS. 

it  may  be  replaced  after  suitable  disinfection;  otherwise  it  should  be  excised,  pro- 
vided its  extent  is  not  too  great.  After  excision  or  reposition  a  gauze  drain  should  be 
placed  down  to  the  affected  part  of  the  pancreas. 

Wounds  of  the  Pancreas. — Injuries  of  the  pancreas  are  quite  rare.  This  can 
be  accounted  for  by  its  deep  situation  upon  the  posterior  wall  of  the  abdomen,  pro- 
tected anteriorly  by  the  costal  margin,  liver,  stomach,  and  intestine,  and  posteriorly 
by  the  vertebral  column,  kidneys,  etc.  Isolated  injuries  are  therefore  extremely  rare, 
and  the  wounds  of  neighboring  organs  often  cause  the  death  of  the  patient  from 
shock  or  hemorrhage  before  the  surgeon  can  interfere,  or  after  the  abdomen  is  opened 
so  obscure  the  picture  that  the  pancreatic  injury  is  overlooked. 

Animal  experiments  show  that  injuries  of  the  pancreas  are  not  in  themselves 
fatal ;  in  fact,  as  shown  by  the  experiments  of  Minkowski  and  von  Mering,  total  ex- 
tirpation of  the  organ  is  not  immediately  fatal.  Mugnai  also  found  that  wounds  of 
the  pancreas  in  animals  are  well  borne.  There  has  been  considerable  discussion  as 
to  whether  or  not  leakage  of  pancreatic  secretion  into  the  peritoneum  is  injurious. 
Senn  considered  the  secretion  from  a  pancreatic  wound  to  be  harmless,  provided  it 
did  not  become  infected;  on  the  contrary,  Biondi  found  that  it  could  give  rise  to 
peritonitis.  Hildebrandt  and  Dettmer  showed  that  procedures  which  dam  up  the 
pancreatic  secretion  or  cause  a  leakage  of  pancreatic  fluid  into  the  peritoneum  pro- 
duce a  fat  necrosis  in  the  gland  itself  and  in  the  surrounding  tissues.  Clinical  ex- 
perience and  the  experiments  of  Williams,  Flexner,  Katz,  Winkler,  and  others  con- 
firm this  observation.  Mikulicz  thought  that  the  leakage  of  pancreatic  juice  re- 
duces the  resistance  of  the  peritoneum  to  such  an  extent  that  bacterial  invasion  and 
peritonitis  readily  ensue.  His  statistics  seem  to  show  that  the  prognosis  of  an  opera- 
tion becomes  much  worse  when  the  pancreas  is  injured.  Of  ninety-one  cases  of 
resection  of  the  stomach,  where  the  pancreas  was  certainly  not  injured,  twenty-five, 
or  27.5  per  cent.,  died  as  the  result  of  the  operation;  of  thirty  cases  in  which  the 
pancreas  was  more  or  less  injured,  21,  or  70  per  cent.,  died,  mostly  of  peritonitis. 
He  also  thought  that  the  secretion  from  an  injured  or  inflamed  pancreas  can  cause  a 
variety  of  aseptic  peritonitis  with  paralysis  of  the  intestine  and  symptoms  of  in- 
testinal obstruction. 

We  distinguish  subcutaneous  and  open  wounds  of  the  pancreas.  The  former  are 
usually  due  to  blows  upon  or  crushes  of  the  upper  abdomen,  which  press  the  pancreas 
against  the  vertebral  column  and  lacerate  or  even  divide  the  organ.  They  are  most 
frequently  the  result  of  horse  kicks,  being  run  over  by  vehicles,  or  being  caught 
between  cars.     Penetrating  wounds  are  usually  of  gunshot  origin  or  stabs. 

The  diagnosis  of  pancreatic  injuries  is  very  difficult;  in  fact,  there  are  very  few 
cases  on  record  in  which  the  diagnosis  has  been  made  before  operation,  except  cer- 
tain cases  operated  upon  several  days  after  the  injury,  in  which  the  appearance  of  a 
circumscribed  area  of  dullness  and  resistance  in  the  epigastrium  following  upon  the 
acute  symptoms,  namely,  pain  and  tenderness,  vomiting,  evidences  of  loss  of  blood, 
or  shock,  pointed  to  a  pancreatic  injury.  Since  isolated  injuries  are  so  rare,  the 
picture  is  generally  governed  b-y  symptoms  due  to  the  injury  of  some  other  organ,  such 


WOUNDS    OF   THE    PANCREAS.  577 

as  the  liver,  stomach,  or  intestine,  and  in  these  cases  the  injury  to  the  pancreas  is  not 
infrequently  overlooked. 

In  cases  of  subcutaneous  or  penetrating  wounds  of  the  upper  abdomen  it  is  there- 
fore important  to  always  examine  the  pancreas.  As  Mikulicz  has  aptly  said: 
"  The  indication  for  operation  does  not  depend  upon  the  diagnosis  of  an  injury  to 
the  pancreas  itself,  but  also  upon  the  severity  of  all  the  symptoms,  especially  and 
particularly  the  steady  accentuation  of  such  symptoms.  These  symptoms  are  in- 
creasing anemia,  the  physical  signs  of  blood  in  the  peritoneal  cavity,  and  peritoneal 
irritation.  An  injury  to  the  neighboring  organs  can  frequently  occasion  the  same 
symptoms,  and,  as  a  rule,  it  is  not  important  to  diagnose  that  the  pancreas  itself  has 
been  injured." 

Operation  being  decided  upon,  the  incision  is  best  made  in  the  mid-line  above  the 
umbilicus  or  through  the  inner  edge  of  the  rectus  muscle.  It  can  be  easily  enlarged 
by  lateral  incisions,  and  if  the  exposure  is  still  insufficient  the  left  costal  margin  can 
be  divided  and  retracted  outward.  The  pancreas  is  exposed  by  an  opening  in  the 
gastrocolic  omentum. 

If  a  wound  is  discovered  in  the  pancreas  it  is  important  to  stop  the  hemorrhage 
and  prevent  the  spread  of  pancreatic  fluid.  This  is  best  done  by  means  of  deep 
sutures  of  catgut  and  by  packing.  In  inserting  the  deep  sutures  one  should  avoid 
injuring  such  important  structures  as  the  superior  mesenteric  and  splenic  vessels. 
If  the  main  duct  has  been  divided,  it  may  be  sutured,  but  an  accurate  approximation 
of  the  surrounding  parenchyma  will  probably  be  sufficient.  In  the  case  of  wounds 
produced  by  blunt  force,  where  the  gland  is  extensively  crushed,  sutures  may  be 
inadvisable  and  a  large  pack  necessary. 

In  1903  Mikulicz^  collected  forty-five  cases  of  pancreatic  injury,  twenty-one 
penetrating  wounds  and  twenty-four  subcutaneous  wounds.  Of  the  twenty-one 
penetrating  wounds,  twelve  were  of  gunshot  origin  and  nine  were  stab  wounds.  Of 
the  gunshot  wounds,  five  were  operated  upon,  two  dying  and  three  recovering.  The 
seven  that  were  not  operated  upon  died.  The  nine  stab  wounds  were  all  operated 
upon,  one  dying  and  eight  recovering.  The  remarkably  favorable  percentage  of 
recovery  in  stab  wounds  is  to  be  explained  by  the  fact  that  in  seven  cases  the  pan- 
creatic injury  was  really  a  prolapse,  and  in  some  of  the  cases  only  a  minor  injury 
of  the  prolapsed  portion  was  present.  The  evil  consequences  of  injuries  to  the  pan- 
creas within  the  peritoneal  cavity  could  therefore  not  follow. 

Of  the  twenty-four  subcutaneous  injuries,  thirteen  were  not  operated  upon  and 
all  died.  Of  eleven  operated  upon,  seven  recovered.  The  operation  consisted  in 
exposing  the  injured  pancreas  and  drainage. 

Since  Mikulicz's  publication  cases  of  gunshot  wound  of  the  pancreas  which  were 

operated  upon  with  recovery  have  been  reported  by  Borchardt  and  Becker.    Becker's 

case  is  the  only  one  of  isolated  gunshot  wound  of  the  pancreas  on  record.     Cases  of 

subcutaneous  wound  of  the  pancreas  which  were  operated  upon  and  recovered  have 

been  reported  by  Garre,  Blecher,  Thole,  Beneke,  and  others. 

^  Mikulicz:  Loc.  cit. 
VOL.  II — 37 


578  SURGICAL   TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 

Among  the  complications  and  sequelae  of  pancreatic  injuries  we  may  mention  in- 
flammation and  abscesses,  necrosis,  and  cysts  of  the  pancreas,  one-fourth  of  pan- 
creatic cysts  being  said  to  be  of  traumatic  origin. 

Acute  Hemorrhagic  and  Gangrenous  Pancreatitis. — Although  the  question 
as  to  the  best  treatment  of  acute  pancreatitis  has  been  freely  discussed  in  recent 
years,  it  is  not  yet  settled.  Many  surgeons  are  still  averse  to  early  operation,  argu- 
ing that,  inasmuch  as  the  results  of  operative  interference  are  more  favorable  after 
the  formation  of  a  localized  abscess,  one  should  wait  until  such  an  abscess  forms 
before  operating.  This  argument,  however,  is  fallacious,  as  it  does  not  consider  the 
large  percentage  of  those  who  die  before  such  a  favorable  condition  is  presented; 
and,  in  the  second  place,  many  patients  never  develop  a  localized  abscess,  the  process 
being  diffuse  from  the  beginning. 

A  number  of  surgeons,  among  them  Korte,  who  formerly  advised  against  opera- 
tion in  the  early  stages,  now  advise  early  operation.  One  of  the  first  to  advise  operat- 
ing in  the  first  stages  of  acute  pancreatitis  was  Hahn,^  who,  considering  the  collapsed 
condition  of  most  of  these  cases,  recommended  a  small  incision  in  the  middle  line 
below  the  umbilicus  and  drainage  for  evacuation  of  the  blood-stained  peritoneal 
fluid.  He  thought  the  high  mortality  after  operation  in  such  cases  was  to  some  ex- 
tent due  to  the  fact  that  the  operation  was  undertaken  with  the  mistaken  diagnosis  of 
peritonitis  or  intestinal  obstruction,  the  prolonged  search  for  the  perforation  or  ob- 
struction being  badly  borne  by  such  weak  subjects.  This  point  has  also  been  em- 
phasized by  Mikulicz  and  others.  Woolsey,^  who  has  reported  three  cases  operated 
upon  in  a  manner  essentially  similar  to  Hahn's,  with  recovery,  recommends  lapar- 
otomy and  drainage,  and  thinks  extensive  and  prolonged  operations  are  not  justifi- 
able. Pels-Leusden,  Wiesinger,  and  others  have  reported  cases  thus  treated  success- 
fully. 

Halsted,  Pels-TiCusden,  and  Bevan  have  reported  cases  of  acute  pancreatitis 
which  recovered  after  laparotomy  and  closure  without  drainage.  In  some  of  these 
cases  nothing  more  was  done  because  the  collapsed  condition  of  the  patient  would  not 
allow  it. 

The  benefit  derived  from  these  methods  of  operating  is  doubtless  due  to  the  re- 
moval of  the  blood-stained  peritoneal  fluid,  which  is  very  toxic.  Doberauer^  and 
Guleke*  have  shown  that  the  critical  condition  of  patients  with  acute  pancreatitis 
is  due  to  a  trypsin  intoxication,  the  intensity  of  the  intoxication  depending  upon  the 
extent  of  the  necrosis  and  the  amount  of  pancreatic  gland  destroyed.  Guleke  has 
succeeded  in  immunizing  animals  against  trypsin. 

Mikulicz  in  1903  advanced  the  view  that  acute  pancreatitis  should  be  treated  as 

*  Hahn:  "Ueber  operativen  Behandlung  bei  Pankreatitis  haemorrhagica,"  Deutsche  med. 
Wochenschr. ,  1901,  Bd.  xxvii,  Vereins  Beilage,  i,  S.  5. 

^Woolsey,  G.:  "The  Diagnosis  and  Treatment  of  Acute  Pancreatitis,"  Annals  of  Surgery, 
1903,  xxxviii,  726. 

^  Doberauer,  Gustav:  "Ueber  die  sogenannte  akute  Pankreatitis  und  die  Ursachen  des 
schweren  oft  todlichen  Verlaufes  derselben,"  Beit.  z.  khn.  Chir.,  1906,  xlviii,  456. 

*  Guleke,  N.:  "Ueber  die  experimentelle  Pankreasnekrose  und  die  Todesursache  bei  acuten 
Pankreaserkrankungen,"  Arch.  f.  klin.  Chir.,  1906,  Ixxviii,  845. 


ACUTE    HEMORRHAGIC   AND    GANGRENOUS    PANCREATITIS.  579 

any  other  phlegmon,  and  that  the  moment  the  condition  is  recognized  the  abdomen 
should  be  opened  and  the  inflamed  peripancreatic  tissues  and  the  pancreas  itself 
incised  and  drained.  He  considered  the  flushing  of  the  abdominal  cavity  with  salt 
solution  to  be  quite  important.  Porter*  and  Muspratt^  have  reported  cases  success- 
fully treated  by  this  method,  deep  incisions  being  made  into  the  pancreas  and  drain- 
age instituted. 

A  study  of  the  literature  reveals  the  striking  frequency  of  the  sequence  of  acute 
pancreatitis  upon  cholelithiasis,  and  a  good  many  cases  are  recorded  in  which  at  the 
operation  for  acute  pancreatitis  gall-stones  were  found  in  the  gall-bladder  and  chole- 
cystostomy  performed,  the  patients  recovering  completely.  Such  cases  have  been 
reported  by  Mayo,  Nash,  Lilienthal,  Kelly,  Robson,  and  others. 

Henle  operated  upon  a  case  in  which  the  diagnosis  of  intestinal  obstruction  had 
been  made.  After  demonstrating  the  presence  of  fat  necroses  in  the  omentum,  a 
large  peritoneal  exudate  was  removed  and  an  artificial  anus  was  established  in  the 
cecum  to  relieve  the  condition  of  intestinal  paralysis.  The  patient  recovered  and 
the  artificial  anus  was  subsequently  closed. 

I  want  to  emphasize  the  importance  of  operating  in  the  early  stages  of  acute  pan- 
creatitis, before  a  secondary  infection  from  the  intestine  renders  the  prognosis  more 
unfavorable.  Inasmuch  as  these  cases  are  seldom  diagnosed  with  absolute  certainty, 
and  are  often  mistaken  for  peritonitis  or  intestinal  obstruction,  the  operation  will 
usually  be  in  the  nature  of  an  exploratory  laparotomy.  The  discovery  of  blood- 
stained fluid  and  the  presence  of  fat  necroses  clinch  the  diagnosis. 

The  exact  nature  of  the  operation  will  depend  upon  the  condition  of  the  patient. 
The  ideal  procedure  would  be  about  as  follows :  Rapid  removal  of  the  peritoneal 
exudate,  perhaps  with  irrigation  of  the  abdominal  cavity  with  salt  solution ;  exposure 
of  the  pancreas  through  the  gastrocolic  omentum,  incision  of  the  swoUen,  inflamed 
gland,  and  introduction  of  a  large  gauze  tampon;  examination  of  the  gall-bladder 
and  bile-passages;  removal  of  calcuh,  if  present,  and  cholecystostomy.  As  a  matter 
of  fact,  such  a  procedure  will  probably  seldom  be  warranted  and  must  be  modified 
to  suit  the  case.  The  simplest  procedure  is  that  advocated  by  Hahn,  namely,  lapar- 
otomy and  drainage  of  the  peritoneal  exudate.  However,  it  seems  to  me  that  a 
rapid  exposure  of  the  pancreas  and  the  introduction  of  a  large  tampon,  perhaps  with 
incision  into  the  gland,  will  cause  very  httle  more  shock  and  offer  better  prospects  of 
cure.  A  larger  experience  will  probably  show  which  procedures  will  cause  the 
smallest  amount  of  surgical  shock,  while  still  accomplishing  the  object  for  which  they 
are  undertaken. 

Mikulicz  in  1903  collected  forty-six  cases  of  acute  pancreatitis,  which  had  been 
operated  upon  in  the  acute  stage  with  only  nine  recoveries.  On  the  contrary,  eighteen 
out  of  thirty-five  cases  recovered  when  the  operation  was  done  in  the  later  stages. 
He  states,  however,  very  rightly  that  such  statistics  are  of  very  little  value,  for,  as  he 

1  Porter,  C.  A.:  "Pancreatitis;  Operation;  Recovery,"  Boston  Med.  and  Surg.  Jour.,  1903, 
cxlix,  430. 

^Muspratt,  Charles  D.:  "Acute  Hgemorrhagic  Pancreatitis;  Operation;  Recovery."  Brit. 
Med.  Jour.,  Feb.  5,  1904,  i,  p.  304. 


580  SURGICAL   TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 

says:  "First  of  all,  we  do  not  know  from  the  statistics  available  at  present  how  nianv 
of  these  patients  with  acute  pancreatitis  really  survive  the  acute  stage,  and  go  on  to 
the  subacute,  the  most  favorable  stage  for  operation.  I  believe  that  comparative 
statistics  in  this  regard  will  show  that  the  great  majority  of  the  patients  die  in  the 
acute  stage.  The  possibility  that  a  goodly  number  could  be  saved  by  a  rationally 
conducted  early  operation  cannot  at  present  be  denied." 

Bloodgood  in  1904  collected  seventy-five  cases  of  acute  hemorrhagic  pancreatitis, 
of  which  twenty-five  recovered  and  fifty  died.  Of  the  twenty-five  which  recovered, 
eighteen  had  been  operated  upon,  the  remaining  seven  recovering  without  operation. 
Of  the  fifty  which  died,  twenty-three  had  been  operated  upon. 

In  21,000  admissions  to  the  surgical  service  of  the  Johns  Hopkins  Hospital  there 
have  been  only  four  cases  of  acute  hemorrhagic  pancreatitis.  All  of  these  were 
operated  upon  in  the  early  stage,  with  one  recovery.  Two,  including  the  case  which 
recovered,  were  closed  without  drainage.  In  the  other  two  a  gauze  tampon  was 
placed  down  to  the  pancreas. 

Pancreatic  Apoplexy. — The  relation  which  hemorrhage  into  the  gland  and 
hemorrhagic  pancreatitis  bear  to  one  another  is  not  very  clear,  and  in  reviewing 
the  reported  cases  it  is  often  difficult  to  distinguish  between  them.  There  is  little 
doubt,  however,  that  genuine  cases  of  pancreatic  hemorrhage  without  preceding  in- 
flammation of  the  gland  do  occur,  but  the  hematoma  so  soon  becomes  infected  that 
the  case  to  all  intents  and  purposes  is  one  of  acute  pancreatitis,  and  what  has  just 
been  said  regarding  the  treatment  of  acute  hemorrhagic  pancreatitis  applies  also  to 
these  cases.  They  are  quite  rare,  are  usually  rapidly  fatal,  and  are  seldom  cured  by 
surgical  intervention. 

Bunge^  has  reported  a  case  of  pancreatic  apoplexy  which  recovered  after  lapar- 
otomy and  extensive  drainage  of  the  lesser  peritoneum. 

I  have  seen  two  cases  of  pancreatic  apoplexy  at  the  Johns  Hopkins  Hospital 
which  were  thus  treated,  but  both  died.  In  one  of  these  there  was  an  extensive 
hemorrhage  into  the  head  of  the  pancreas  and  into  the  retroperitoneal  tissues  behind 
the  ascending  colon;  in  the  other  the  lesser  peritoneal  cavity  was  filled  with  necrotic 
blood-clot  and  there  were  extensive  infiltrations  of  the  transverse  mesocolon  and 
into  the  tissues  behind  the  descending  colon. 

Suppurative  Pancreatitis ;  Pancreatic  Abscess. — Those  cases  of  acute  pan- 
creatitis which  proceed  to  suppuration,  the  subacute  form  of  Robson  and  Moynihan, 
are  of  particular  interest,  since  they  are  especially  amenable  to  surgical  treatment. 
In  the  majority  of  these  cases  the  onset  is  as  acute  as  in  the  hemorrhagic  form,  but  the 
symptoms  are,  as  a  rule,  less  severe^  and  the  process  is  not  of  sufficient  extent  and 
gravity  to  cause  death.  Somewhat  later  the  necrosis  and  secondary  infection  give 
rise  to  the  formation  of  more  or  less  extensive  abscesses,  containing  larger  or  smaller 
portions  of  the  sequestrated  pancreas.  Considering  the  satisfactory  results  of 
prompt  surgical  intervention,  the  early  diagnosis  of  these  cases  is  very  important, 

^  Bunge:  "Zur  Pathogenese  unci  Therapie  der  acuten  Pankreashamorrhagie  und  abdomi- 
nalen  Fettgewebsnekrose,"  Arch.  f.  klin.  Chir.,  1903,  Ixxi,  726. 


CHRONIC    PANCREATITIS.  581 

especially  since  grave  complications  are  prone  to  arise,  such  as  liver  abscess,  sub- 
phrenic abscess,  thrombosis  of  the  portal  vein,  exhaustion,  etc. 

Diffuse  suppuration  or  abscesses  confined  to  the  pancreas  are  seldom  seen,  since 
the  pus  is  very  liable  to  burrow  into  the  peripancreatic  tissues  and  lesser  peritoneum, 
often  giving  rise  to  a  tumor,  which  can  be  more  or  less  clearly  defined  before  opera- 
tion and  which  facilitates  the  diagnosis.  The  tumor  usually  presents  in  the  mid- 
line below  the  stomach,  but  occasionally  above  the  stomach,  or  it  may  extend  well 
over  into  the  left  flank,  giving  rise  to  the  mistaken  diagnosis  of  perinephritic  abscess. 

Spontaneous  healing  without  operation  is  unusual,  but  cases  where  the  diagnosis 
was  confirmed  have  been  recorded,  in  which  recovery  took  place  after  the  rupture  of 
the  pancreatic  abscess  into  the  intestine.  Robson^  has  reported  such  a  case,  and 
another  in  which  the  abscess  ruptured  into  the  stomach  and  recovery  followed  a 
gastro-enterostomy. 

Cases  of  diffuse  suppuration  or  small  multiple  abscesses  offer  little  hope  of  suc- 
cessful surgical  treatment,  but  with  a  large  localized  abscess  the  outlook  is  much 
brighter. 

The  diagnosis  is  often  not  determined  until  the  abdomen  is  opened.  The  in- 
cision is  usually  made  in  the  median  line  or  through  the  rectus  muscle  over  the  most 
prominent  part  of  the  tumor  mass.  If  the  examination  shows  the  presence  of  a 
pancreatic  abscess,  the  abdominal  cavity  is  packed  off  with  gauze  and  the  abscess 
opened,  usually  through  the  gastrocolic  omentum,  evacuated  and  drained  with 
gauze  or  by  means  of  a  rubber  tube  surrounded  with  gauze.  It  is  generally  preferred 
to  complete  the  operation  in  one  stage,  but  it  can  be  done  in  two  stages,  the  abscess 
first  being  walled  off  with  gauze  or  by  suturing  its  wall  to  the  parietal  peritoneum  and 
opened  later,  after  adhesions  have  formed. 

To  secure  better  drainage,  especially  when  the  abscess  extends  well  toward  the 
flank,  it  is  sometimes  advisable  to  make  an  incision  in  the  costovertebral  angle,  and 
by  blunt  dissection,  passing  in  front  of  the  lower  pole  of  the  kidney,  to  open  a  path 
for  drainage. 

In  recent  years  numerous  cases  have  been  reported  in  which  recovery  followed 
operations  for  pancreatic  abscess.  Thayer^  has  reported  four  cases  operated  upon 
by  Halsted,  Finney,  and  Bloodgood,  three  of  which  recovered.  Robson^  has  reported 
eight  cases  occurring  in  his  own  practice.  Six  were  operated  upon,  with  recovery 
from  the  operation  in  five,  though  in  one  of  the  cases  the  relief  was  only  for  a  few 
weeks  and  in  another  for  a  few  months. 

Chronic  Pancreatitis. — Those  chronic  inflammations  of  the  pancreas  arising 
from  general  causes,  such  as  syphilis  and  alcoholism,  and  certain  local  causes, 
such  as  gastro-intestinal  catarrh  and  local  circulatory  disturbances,  are  not  amenable 
to  surgical  treatment,  though  their  effect  upon  neighboring  organs  or  the  pancreas 
itself  may  require  such  treatment.     Of  the  former,  the  common  duct  is  most  fre- 

^  Robson,  A.  W.  Mayo:     "Inflammatory  Affections  of  the  Pancreas,"  Lancet,  1904,  i,  845. 

^  Thayer,  Wm.  S.:  "Observations  on  Several  Cases  of  Acute  Pancreatitis,"  Johns  Hopkins 
Hosp.  Bull.,  1905,  xvi,  355. 

^  Robson:  Loc.  cit. 


582  SURGICAL   TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 

quently  involved,  often  being  so  compressed  by  the  head  of  th^  pancreas  that  a  severe 
jaundice  ensues.  The  gall-bladder  is,  as  a  rule,  distended,  whereas  in  cases  of 
biliary  obstruction  due  to  calculi  it  is  usually  contracted. 

Surgeons  at  first  considered  these  to  be  cases  of  carcinoma  of  the  pancreas  and 
were  content  to  do  a  simple  exploration  or  else  joined  the  distended  gall-bladder  to 
the  intestine.  The  surprising  and  gratifying  results  in  many  of  these  cases  gradually 
led  to  the  adoption  of  a  rational  method  of  treatment,  which  aimed  at  the  removal  of 
the  biHary  obstruction  and  at  the  same  time  sought  to  bring  about  a  subsidence  of 
the  inflammatory  process  in  the  head  of  the  pancreas. 

RiedeP  in  1896  first  called  attention  to  the  extremely  hard  tumors  in  the  head  of 
the  pancreas  due  to  chronic  pancreatitis,  emphasized  their  relation  to  gall-stones,  and 
mentioned  their  chronic  course,  recognizing,  however,  that  they  do  subside.  It  is  to 
Robson,^  however,  that  we  owe  the  development  of  the  surgical  treatment  of  this 
condition.  Since  his  publication  the  attention  of  surgeons  has  been  directed  to  this 
disease  and  numerous  cases  have  been  reported  in  which  recovery  has  followed  opera- 
tion. 

When  only  mild  symptoms  are  present,  medical  treatment  should  be  given  a  fair 
trial,  but  the  surgeon  should  not  hesitate  too  long  in  operating  for  chronic  pan- 
creatitis, as  serious  disturbances  of  nutrition  can  result  from  the  gradual  degenera- 
tion of  the  gland.  When  the  operation  is  done  before  the  process  has  advanced  to  a 
well-marked  pancreatitis  or  to  the  interacinar  form,  a  complete  cure  is  effected  in  a 
large  proportion  of  the  cases;  but  if  the  interstitial  changes  have  become  well  marked, 
an  arrest  of  the  process  is  all  that  can  be  hoped  for. 

Owing  to  the  uncertainty  of  the  diagnosis  of  this  condition  the  operation  will 
usually  be  an  exploratory  incision  through  the  upper  part  of  the  right  rectus  muscle. 
Even  after  the  abdomen  is  opened  and  the  pancreas  palpated  it  is  sometimes  difficult 
to  decide  whether  we  are  dealing  with  a  chronic  pancreatitis  or  a  carcinoma  of  the 
head  of  the  gland,  though  the  induration  produced  by  the  former  is  somewhat  more 
elastic  than  that  produced  by  the  latter.  The  gall-bladder  is  usually  distended  in 
either  case. 

If  the  condition  is  one  of  chronic  pancreatitis  any  concretions  present  in  the  gall- 
bladder, bile-ducts,  or  duct  of  Wirsung  should  be  removed,  and  at  the  same  time  the 
bile-ducts  should  be  drained  either  by  cholecystostomy  or  cholecystenterostomy. 
Even  though  no  gall-stones  or  pancreatic  calculi  are  present  drainage  of  the  bile- 
ducts  by  one  of  these  methods  is  very  important.  According  to  Robson,  the  drain- 
age of  the  bile-ducts  acts  not  only  by  removing  one  source  of  irritation  in  the  shape 
of  infected  bile,  but  at  the  same  time  it  relieves  tension  and  allows  the  escape  of  the 
infected  pancreatic  secretion,  besides  freeing  the  blood  and  the  system  at  large  from 
a  poison  which  seriously  damages  them. 

^  Riedel:  "Die  chronische  zur  Bildung  eisenharter  Tumoren  fi'ihrende  Entziindung  der 
Schilddriise,"  Deutsche  med.  Wochenschr.,  1896,  xxii,  V.  120. 

^Robson,  A.  W.  Mayo:  "Pancreatitis,  with  especial  Reference  to  Chronic  Pancreatitis," 
Lancet,  1900,  ii,  235;  "On  the  Pathology  and  Surgery  of  Certain  Diseases  of  the  Pancreas," 
Lancet,  1904,  i,  773. 


PANCREATIC    LITHIASIS.  583 

Cholecystostomy  and  cholecystenterostomy  both  have  their  advantages  and  dis- 
advantages. The  technic  of  the  first,  which  is  recommended  by  Robson,  is  more 
simple  and  does  not  permit  a  permanent  infection  of  the  bihary  tract  from  the  con- 
tents of  the  intestine.  It  has  the  disadvantage  that  the  patient  is  burdened  for  a 
long  time  with  an  external  fistula,  which  may  prove  difficult  to  close.  The  experi- 
ments of  Radziewski  would  indicate  that  the  importance  of  a  retrograde  infection  of 
the  bile-ducts  from  the  intestinal  fistula  has  been  overestimated.  The  danger  of 
infection  is  lessened  if,  after  cholecystenterostomy,  an  entero-anastomosis  is  im- 
mediately added  at  a  distance  of  about  10  cm.  from  the  original  anastomosis,,  which 
deflects  the  intestinal  contents  from  the  loop  connected  with  the  gall-bladder. 
Gastro-enterostomy  avoids  the  external  fistula,  but  is  a  more  extensive  procedure  and 
is  attended  by  greater  danger  to  the  patient. 

Barth^  and  Martina^  have  each  reported  a  case  of  chronic  pancreatitis  in  which 
the  severe  epigastric  pain  was  refieved  by  incising  the  thickened,  infiamed  peritoneum 
covering  the  gland.  Martina  thought  that  in  his  case  the  reHef  of  the  pain,  which 
was  worse  after  taking  nourishment,  was  due  to  the  fact  that  the  incision  allowed  the 
expansion  of  the  gland,  which  swells  after  taking  food,  as  a  result  of  the  increased 
blood-supply. 

Robson  in  1904  reported  the  following  results  of  his  operations  for  chronic  pan- 
creatitis. In  twenty-seven  cases  of  catarrhal  or  interstitial  pancreatitis,  where 
gall-stones  were  found  obstructing  the  pancreatic  portion  of  the  common  duct, 
choledochotomy  in  nineteen,  cholecystostomy  in  five,  and  cholecystenterostomy  in 
three  were  followed  not  only  by  immediate  but  by  permanent  recovery,  except 
one  who  died  later  of  acute  bronchitis,  one  who  has  cirrhosis  of  the  liver,  and 
one  who  eight  and  a  half  years  after  the  operation  was  apparently  well  but 
had  sugar  in  the  urine.  In  twenty-four  cases  where  obstruction  to  the  common 
bile-duct  was  due  to  an  inflammatory  condition  of  the  pancreas  compressing  the 
bile-duct,  though  probably  in  many  cases  originally  due  to  gall-stones,  yet  where 
gall-stones  were  not  present  at  the  time  of  operation,  the  bile-ducts,  and  thus  in- 
directly the  pancreatic  ducts,  were  drained,  in  twelve  cases  by  cholecystostomy 
and  in  nine  by  cholecystenterostomy ;  in  three  cases  adhesions  were  separated  and  no 
drainage  of  the  })ile-ducts  was  performed.  Of  these  twenty-four  cases,  twenty-two 
recovered,  of  which  eighteen  could  be  traced  at  the  time  of  his  report  and  were 
found  to  be  well.  We  thus  see  that  only  two  out  of  fifty-one  cases  died  as  a  direct 
result  of  the  operation. 

Besides  his  own  cases,  fifty-one  in  number,  Robson  found  sixty-two  operations 
for  chronic  pancreatitis  recorded,  of  which  eight  died,  giving  a  rate  of  mortality 
of  12.9  per  cent. 

Pancreatic  Lithiasis. — Since  the  presence  of  calculi  in  the  pancreas  may  give 
rise  to  serious  disturbances  in  the  organ,  such  as  dilatation  of  the  duct  of  Wirsung, 

1  Barth:    "Ueber  indurative  Pankreatitis,"  Verh.  d.  Deutschen  Ges.  f.  Chir.,  1904,  xxxiii,  376. 

2  Martina,  A.:  "Ueber  chronische  interstitielle  Pankreatitis,"  Deutsche  Zeit.  f.  Chir.,  1907, 
Ixxxvii,  499. 


584 


SURGICAL    TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 


abscess  formation,  and  atrophy  of  the  gland,  it  is  important  that  they  be  recognized 
early  and  removed  as  soon  as  possible.  The  diagnosis  is,  however,  difficult  and 
seldom  made  with  any  degree  of  certainty.     Kinnicutt,^  in  1902,  collected  seven 


common  biLe-duct 


cCu  ct  of  IVirsung 


common  bite-duct 


duct  of  IVirsuni 


Fig.  768. — The  Common  Bile-duct  and  Duct  of 
W'^iESuxG  Opening  Separately  at  the  Summit 
OF  THE  Bile  Papilla. 


Fig.  769. — A  Small  Gall-stone  Occluding  the 
Dl'odenal  Orifice  of  the  Diverticulum  of 
Vater  and  Converting  the  Common  Bile-duct 
.iND  the  Duct  of  Wirsung  into  a  Continuous 
Channel. 


cases,  including  one  of  his  own,  in  which  the  diagnosis  was  made,  and  since  his 
publication  several  cases  have  been  reported  in  which  pancreatic  calculi  were  diag- 
nosed and  removed  at  operation. 

In  Gould's  case,"  which  was  not  diagnosed  before  operation,  there  was  jaundice 

and  the  gall-bladder  was  distended.     A 


common  iile-duct 


deed  of  PyCrsung 


large  coral-like  stone  w^as  removed  from 

the  duct  of  Wirsung,  but  the  obstruction 

to  the  flow  of  bile  was  not  removed,  and 

there  was  another   attack  of   agonizing 

pain  in  the  right  hypochondrium.     The 

abdomen  was  again  opened  and  another 

stone  found  in  the  head  of  the  pancreas 

and   removed   by  incising  the  pancreas 

over  it.     A  probe  could  then  be  passed 

through   the   duct   into   the   duodenum. 

The  patient  died  twelve  days  after  the 

operation  from  exhaustion.    In  Dalziel's 

case  a  stone,  the  size  of  a  large  pea, 

was   removed   from  the  pancreatic  duct 

through  an  incision   in   the  duodenum, 

and  the  patient  made  a  good  recovery.     Lisanti  in  1899  reported  a  case  in  which 

recovery  took  place  after  the  transduodenal  removal  of  a  stone  from  the  duct  of 

Wirsung. 

-  Kinnicutt,  Francis  P.:  "Pancreatic  Lithiasis,  with  Report    of  a   Case,"   Am.   Jour.   Med. 
Sciences.  1902,  cxxiv,  948. 

^  Gould,  A.  Pearce:  "Pancreatic  Calculi,"  Lancet,  1898.  ii,  1632. 


C3.icu,Cus. 


Fig.  770. — Large  Gall-stone  Lodged  in  the  Diver- 
ticulum of  V.^ter  AND  Occluding  Both  Common 
Bile-duct  and  Dltct  of  W'irsung. 


PANCREATIC    LITHIASIS. 


585 


^^^ 

^^^^y 


Fig.  771. — Large 
Gall  -  stone 
Which  Had  Oc- 
cluded THE  Di- 
verticulum OF 
Vater  and 

Caused  Chronic 
Interstitial 
Pancreatitis. 


In  Moynihan's  case/  in  which  a  diagnosis  of  chronic  pancreatitis  and  pancreatic 
lithiasis  had  been  made,  a  stone  h  inch  long  and  -^^  inch  in  diameter  w^as  removed 
from  the  orifice  of  the  duct  of  Wirsung  after  incising  the  duodenvim  and  laying  open 
the  ampulla.  In  1903  Robson  ^  operated  upon  a  woman  fifty- 
seven  years  old  and  removed  four  pancreatic  calculi,  one  from 
the  duct  of  Santorini  by  direct  incision  into  the  pancreas  close 
to  the  common  duct,  afterward  closing  the  opening  by  deep  and 
peritoneal  sutures;  the  second  and  third  stones  were  removed 
by  laying  open  the  papilla  through  the  duodenum  and  removing 
the  stones  from  the. duct  of  Wirsung;  a  fourth  concretion  was 
removed  by  direct  pancreatotomy  from  the  middle  of  the  duct 
of  Wirsung,  the  pancreas  being  exposed  through  an  opening  in 
the  gastrohepatic  ligament.  The  duct  was  closed  with  catgut 
and  the  wound  in  the  body  of  the  pancreas  and  the  peritoneal 
covering  were  sutured  without  drainage.  Staehlin  and  Roeber^ 
in  1905  reported  the  case  of  a  woman  thirty-nine  years  old,  in  whom  a  diagnosis  of 
pancreatic  lithiasis  was  made.     At  the  operation  several  calculi  were  found  in  the 

duct  of  Wirsung  in  the  head  of  the  pancreas 
and  removed  through  an  incision  in  the  gland. 
Recovery  followed. 

Several  cases  are  recorded  where  calculi 
were  found  in  abscesses  or  cysts  of  the  pan- 
creas. In  Caparelli's  case,  after  many  attacks 
of  acute  epigastric  colic,  an  abscess  developed 
above  the  umbilicus,  which  burst  and  dis- 
charged pus  and  gritty  material.  Through 
the  fistula,  which  persisted  for  six  years,  many 
small  stones,  over  a  hundred  in  all,  were 
expelled.  After  spontaneous  closure  of  the 
fistula  diabetes  developed  and  the  patient 
died.  Allen  *  found  two  stones  in  a  cyst,  the 
size  of  an  orange,  presenting  above  the 
stomach.  The  cyst  was  drained  and  the  pa- 
tient died  five  days  later.  At  the  autopsy  a 
stone  the  size  of  a  marble  was  found  in  the 
duct  of  Wirsung  near  its  orifice. 
An  incision  through  the  inner  edge  of  the  right  rectus  muscle  is  probably  the 
best  for  removing  calculi  from  the  pancreas,  a  cushion  being  placed  beneath  the 

'  Moynihan,  B-  G.  A.:  "On  Pancreatic  Calculus,"  Lancet.  1902,  ii,  p.  355. 

2  Robson,  A.  W.  Mayo:  "The  Pathology  and  Surgery  of  Certain  Diseases  of  the  Pancreas," 
Lancet,  1904,  i,  p.  911. 

3  Staehlin,  Edward,  and  Wm.  J.  Roeber:  "Clinical  and  Operative  Reports  of  Cases  of  Biliary 
and  Pancreatic  Calculi,"  New  York  Med.  Jour.,  1905,  Ixxxii,  p.  904. 

*  Allen,  Lewis  Whitaker:  "Chronic  Interlobular  Pancreatitis,"  Ann.  Surg.,  1903,  xxxvii,  p. 
741. 


Fig.  772. — A  Large  Gall-stone  Occluding 
Both  Common  Bile-duct  and  Duct  of 
Wirsung;    Method  of  Approach. 


586  SURGICAL   TREATMENT    OF   DISEASES    OF   THE   PANCREAS, 

lumbar  spine  to  bring  the  pancreas  nearer  to  the  surface.  The  orifice  of  the  duct 
of  Wirsung  is  best  explored  through  the  duodenum  by  laying  open  the  ampulla  of 
Vater,  which  can  be  brought  to  the  surface  by  grasping  its  edges  with  forceps; 
the  duct  can  then  be  readily  probed.  If  the  calculus  is  situated  more  deeply  in  the 
ducts,  it  can  be  removed,  after  exposing  the  pancreas  above  or  below  the  stomach, 
by  incising  the  pancreas  and  duct.  The  duct  should  be  sutured  and  the  pancreatic 
tissue  and  peritoneum  likewise  carefully  sutured.  It  will  probably  be  safer  in  most 
cases  to  place  a  gauze  drain  down  to  the  suture,  the  gauze  being  surrounded  by 
rubber  tissue.  When  the  duodenum  has  been  opened  it  must,  of  course,  be  carefully 
sutured.     It  is  not  necessary  to  suture  the  incision  in  the  papilla. 

If  the  calculus  is  felt  in  the  deeper  portions  of  the  head  of  the  gland,  its  posterior 
surface  may  be  explored  by  dividing  the  reflection  of  peritoneum  to  the  right  of  the 
duodenum  and  lifting  the  bowel  and  pancreas  upward  and  to  the  left  (Fig.  589). 
The  calculus  can  then  be  extracted  by  incising  the  pancreas. 

Cysts  of  the  Pancreas. — The  following  are  the  methods  of  treating  pancreatic 
cysts:     (a)  Puncture;    (b)  extirpation;    (c)  incision  and  drainage. 

The  jpuncture  of  cysts  as  a  means  of  diagnosis  or  treatment  is  only  mentioned  in 
order  to  condemn  it,  for  the  dangers  attending  it  are  too  great  and  the  prospect  of 
cure  by  this  means  is  very  remote.  The  dangers  consist  in  the  liability  of  injury 
to  overlving;  viscera  and  blood-vessels,  and  the  leakage  of  the  contents  of  the  cvst 
into  the  peritoneal  cavity.  Cases  have  been  reported  in  which  death  has  resulted 
from  hemorrhage  or  peritonitis  following  this  procedure. 

Extirpation,  which  was  first  carried  out  successfully  by  Bozeman  in  1881,  is 
the  method  of  choice,  if  it  can  be  done  without  endangering  the  patient's  life.  In 
certain  instances  the  cyst  is  bound  to  the  surrounding  structures  by  very  few  adhe- 
sions and  connected  to  the  pancreas  by  such  a  small  pedicle  that  it  can  be  extirpated 
without  great  difficulty.  As  a  rule,  the  nearer  its  pedicle  is  to  the  tail  of  the  pancreas, 
the  easier  is  the  removal  of  the  cyst. 

Generally,  however,  the  cyst  wall  is  so  intimately  adherent  to  important  struc- 
tures that  the  dangers  attending  its  removal  render  such  a  measure  inadvisable. 
The  structures  most  liable  to  injury  are  the  stomach,  intestine,  splenic  and  mesen- 
teric vessels.  In  extirpating  pancreatic  cysts  Mikulicz  had  to  ligate  the  splenic 
artery  and  Billroth  both  the  splenic  artery  and  vein. 

Many  authors  advise  the  total  excision  of  cystadenomata  (proliferating  cysts) 
of  the  pancreas  on  account  of  the  danger  of  their  becoming  mahgnant,  though  this 
danger  is  probably  not  a  very  realj^ne.  Roswell  Park  says:  "These  may  some- 
times evince  malignancy,  many  of  them  being  so  close  to  the  border-line  between 
proliferating  cystoma  and  cystic  carcinoma  that  only  the  subsequent  course  of 
events  would  indicate  on  which  side  of  the  line  they  belong." 

Cystadenomata  have  been  removed  by  Poncet,^  Martin,^  Dunning,'^  and  others. 

'Cibert:  "Gros  kysteglandulaire  de  la  queue  du  pancreas,  etc.,"  Gaz.  des  Hop.,  1896,  Ixix, 
p.  .347. 

^  Martin,  A.:  "Ein  Fall  von  Pankreascyste,"  Virchow's  Archiv,  1890,  cxx,  S.  2.30. 

'  Dunning,  L.  H.:  "Cystadenoma  of  the  Pancreas,"  etc..  Am.  Jour.  Obst.,  1905,  li,  p.  101. 


CYSTS    OF   THE   PANCREAS.  587 

Lazarus  ^  collected  twenty-four  cases  in  which  pancreatic  cysts  had  been  ex- 
tirpated. Of  these,  eighteen  recovered  and  six  died;  of  ten  cases  in  which,  on 
account  of  difficulties,  the  cyst  was  only  partially  removed,  six  died,  death  being  due 
to  gangrene  of  the  intestine,  peritonitis,  hemorrhage,  or  exhaustion. 

Incision  and  drainage  may  be  considered  the  normal  method  of  dealing  with 
cysts  of  the  pancreas.  It  w^as  done  successfully  by  Kulenkampff  in  1882  and  by 
Gussenbauer  in  1883.  Its  drawbacks  are  that  the  cyst  occasionally  recurs  and 
that  the  fistula  is  sometimes  of  long  duration.  Statistics  show  that  the  likelihood 
of  recurrence  is  very  slight,  except  those  cysts  complicated  by  new-growths,  where 
extirpation  is  often  indicated. 

The  incision  of  the  cyst  can  be  done  from  the  front  by  the  transperitoneal  route, 
or  from  behind  by  the  extraperitoneal  method  (Bardenheuer).  The  posterior 
operation,  which  is  sometimes  indicated  in  the  case  of  suppurating  cysts  of  the  tail 
of  the  pancreas,  avoids  the  danger  of  peritonitis,  but,  on  account  of  the  danger  of 
injuring  large  blood-vessels,  the  ureter,  and  intestine,  may  be  technically  difficult. 
In  the  case  of  cysts  which  present  in  the  epigastrium  or  right  hypochondrium, 
the  exposure  from  the  front  is  the  simplest  and  most  satisfactory  method.  The 
operation  may  be  done  in  one  stage,  the  cyst  being  attached  to  the  abdominal  wall 
and  immediately  opened  and  drained;  or  in  two  stages,  the  cyst  being  opened  a 
day  or  two  after  its  wall  has  been  sutured  to  the  parietal  peritoneum.  The  one- 
stage  operation  is  performed  more  frequently  than  the  two-stage  operation.  Accord- 
ing to  the  statistics  of  Korte  (loc.  cit.),  of  eighty-four  cases  operated  upon  in  one  stage, 
four  died  from  the  operation,  four  later  of  malignant  growth,  and  two  of  diabetes; 
of  seventeen  operated  upon  in  two  stages,  none  died  directly  as  the  result  of  the  opera- 
tion, but  one  died  shortly  after  his  discharge  from  the  hospital,  presumably  of  dia- 
betes. The  danger  of  the  one-stage  operation  is  the  leakage  of  the  contents  of  the 
cyst  into  the  peritoneal  cavity,  but  this  fluid  is  usually  sterile,  except  in  suppurating 
cysts,  and,  moreover,  leakage  into  the  abdominal  cavity  can  usually  be  avoided  if 
the  operation  is  done  with  care. 

The  one-stage  operation  is,  according  to  Korte's  experience,  the  normal  pro- 
cedure. The  skin  incision  will  vary  with  the  position  of  the  cyst,  but  will  usually 
lie  over  its  most  prominent  portion.  After  opening  the  abdomen  there  are  three  ways 
of  approach  to  the  cyst:  (1)  Pancreatotomia  supraventricularis;  (2)  pancreato- 
tomia  gastrocolica;  (3)  pancreatotomia  mesocolica. 

The  first  method,  which  leads  through  the  gastrohepatic  omentum,  is  indicated 
where  the  cyst  presents  between  the  stomach  and  the  liver.  After  dividing  the 
gastrohepatic  omentum  the  cyst  may  be  sutured  to  the  abdominal  wall  and  drained. 
As  a  rule,  however,  the  exposure  of  the  cyst  wall  above  the  stomach  is  difficult, 
for  it  is  frequently  intimately  adherent  to  the  stomach,  liver,  and  even  to  the  abdo- 
minal wall.  In  a  case  where  the  cyst  was  densely  adherent  to  the  left  lobe  of  the 
liver,  Rasumowsky  made  an  opening  into  the  cyst  through  the  edge  of  the  liver  by 

^Lazarus,  Paul:  "Beitrag  zur  Pathologie  und  Therapie  der  Pankreaserkrankungen,  etc.," 
Zeitschr.  f.  klin.  Med.,  1904,  li,  p.  101. 


588 


SURGICAL   TREATMENT    OF    DISEASES    OF   THE   PANCREAS. 


means  of  a  thermocautery.  Where  the  cyst  is  situated  behind  the  stomach  and  ad- 
herent to  its  posterior  wall,  the  exposure  of  the  cyst  may  be  complicated.  In  such 
a  case  Bessel  Hagen^  incised  the  anterior  and  posterior  walls  of  the  stomach  and 


Fig.  773. — Exposure  of  the  Pancreas  through  the  Gastrocolic  Omentum. 

thus  evacuated  the  cyst.     After  suturing  the  wounds  in  the  stomach,  the  lower 

pole  of  the  collapsed  cyst  was  brought  up,  sutured  to  the  abdominal  wall  and  drained. 

The  posterior  route  would  probably  be  better  in  such  cases. 

^Bessel  Hag;en,  F.:    "  Zur  operativen  Behandlung  der  Pankreascysten,"  Arch.  f.  klin.  Chir., 
1900,  Bd.  Ixii,  S.  157. 


CYSTS    OF   THE   PANCREAS. 


589 


The  pancreatotomia  gastrocolica  is  adapted  to  cysts  presenting  between  the 
stomach  and  transverse  colon,  and  is  the  method  most  often  employed  in  draining 
pancreatic  cysts.  A  good  exposure  is  obtained  by  dividing  the  gastrocolic  omentum, 
elevating  the  stomach,  and  drawing  the  colon  downward.  After  carefully  suturing 
the  cyst  to  the  parietal  peritoneum  with  silk  or  catgut,  the  abdominal  wound  may 
be  partially  closed  and  the  cyst  then  opened  and  drained.     Some  condemn  aspirat- 


FiG.  774. — Exposure  of  the  Posterior  Surface  of  the  Head  of  the  Pancreas  after  Incising  the  Perito- 
neum TO  THE  Right  of  the  Duodenum. 

ing  and  emptying  the  cyst  before  attaching  it  to  the  abdominal  wall,  since  the  wall 
of  the  collapsed  cyst  is  then  brought  forward  and  sutured  with  difficulty. 

The  author  has  recently  had  a  case  which  was  treated  very  satisfactorily  in  the 
following  manner,  which  is  very  similar  to  his  method  of  treating  acute  cholecysti- 
tis and  hydrops  of  the  gall-bladder:  The  incision  was  made  through  the  left  rectus 
muscle  over  the  most  prominent  portion  of  the  tumor.  The  large  cyst  presented 
between  the  stomach  and  transverse  colon,  but  was  so  covered  by  stomach  that  its 


590 


SUEGICAL    TREATMENT    OF    DISEASES    OF   THE    PANCREAS. 


exposed  portion  was  at  some  distance  from  the  anterior  abdominal  wall,  to  which  it 
could,  therefore,  not  be  sutured.  The  general  cavity  was  walled  off  with  gauze, 
the  gastrocolic  omentum  was  divided,  and  the  greater  part  of  the  contents  of  the 
cyst  removed  by  means  of  a  large  aspirating  syringe;  the  cyst  was  then  incised,  its 
edges  grasped  with  forceps  (Fig.  775),  and  the  remaining  fluid  wiped  out  with 
sponges.  A  large  rubber  drainage-tube  covered  with  gauze  was  fastened  into  the 
opening  by  means  of  a  purse-string  suture  of  catgut  and  the  abdominal  wound  closed 
up  to  the  drain.     The  patient  made  an  uneventful  recovery. 


Fig.  775. — Cyst  ok  Pancreas  Which  Has  Been  Emptied.     Abdominal  Packing  Removed.     (Author's  case.) 


The  pancreatotomia  mesocolica  is  used  when  the  cyst  presents  below  the  trans- 
verse colon,  having  pushed  the  transverse  mesocolon  downward  and  forward.  The 
mesocolon  should  be  divided  carefully  to  avoid  injuring  important  vessels. 

After  opening  a  cyst  its  interior  should  be  examined  with  the  fingers  and  a 
sound  to  determine  the  presence  of  tumors,  calcuU,  other  cysts,  etc.  The  cyst 
can  be  drained  by  means  of  gauze  or  rubber  tubing.  The  author  prefers  the  latter 
method,  the  tube  being  surrounded  by  a  layer  of  gauze. 

The  amount  of  secretion  following  the  drainage  of  a  pancreatic  cyst  varies 
greatly.     In  Cushing's  case  ^  it  amounted  to  500  to  600  c.c.  in  twenty-four  hours. 

^  Gushing,  H.  W.:  "  Traumatic  Rupture  of  the  Pancreas,"  etc.,  Boston  Med.  and  Surg.  Jour., 
1898,  cxxxviii,  429. 


SOLID    TUMORS    OF   THE    PANCREAS.  591 

As  a  rule,  the  amount  decreases  rapidly,  the  cavity  contracts,  and  generally  in  from 
four  to  six  weeks  only  a  small  fistula  with  a  moderate  amount  of  discharge  remains. 
This  fistula  may,  however,  last  a  long  time  and  cause  serious  inconvenience.  (See 
Pancreatic  Fistulse.)  Pancreatic  ferments  may  appear  in  the  secretion  a  few  days 
or  weeks  after  the  operation,  though  they  may  not  have  been  present  in  the  contents 
of  the  cyst.  In  a  good  number  of  cases  polyuria  and  diabetes  have  been  observed 
after  the  operation.  The  glycosuria  may  be  the  result  of  extensive  injury  to  the 
gland  or  due  to  the  progress  of  pancreatic  disease  which  existed  before  the  operation. 

The  healing  process  in  cysts  wliich  have  been  opened  and  drained  takes  place  in 
the  following  manner:  After  being  emptied,  the  walls  of  the  cyst  collapse,  granu- 
late, and  grow  together.  Since  only  those  which  are  not  covered  with  epithelium 
can  granulate,  the  pseudo-cysts  heal  much  more  rapidly  than  the  true  cysts,  which 
can  only  heal  after  their  epithelial  lining  has  been  cast  off. 

In  1904  Robson  ^  collected  160  cases  of  pancreatic  cyst  which  had  been  operated 
upon.  Of  these,  140  recovered  and  20  died  as  the  result  of  the  operation.  In  138 
incision  and  drainage  was  performed,  with  16  deaths,  equal  to  a  mortality  of  11.6 
per  cent.  In  15  excision  was  performed,  with  3  deaths,  equal  to  a  mortality  of  20 
per  cent.  Robson  says :  "  These  figures  are  clearly  in  favor  of  incision  and  drainage, 
but  the  mortality  should  be  reduced  by  one-half." 

Solid  Tumors  of  the  Pancreas. — In  the  present  state  of  development  of 
surgery,  when  almost  all  the  regions  of  the  body  are  accessible  to  the  surgeon's 
knife,  the  solid  tumors  of  the  pancreas  are  acquiring  new  interest,  but  thus  far  the 
results  of  operative  interference  arcnot  altogether  encouraging. 

Among  the  benign  tumors  of  the  pancreas  we  find  tuberculoma,  syphiloma,  and 
adenoma. 

Tuberculosis  and  syphilis  of  the  pancreas  do  not  present  a  great  deal  of  surgical 
interest.  Primary  tuberculosis  of  this  organ  is  undoubtedly  rare.  Many  of  the 
cases  of  tuberculosis  of  the  pancreas  doubtless  begin  as  a  tuberculosis  of  neighbor- 
ing lymph-nodes,  which  later  invades  the  pancreas.  It  may  occur  in  the  form  of 
gummatous  nodules  or  as  a  diffuse  interstitial  proliferation.  In  the  case  of  Sendler  " 
the  movable  tumor  in  the  pancreas  proved  to  be  a  tuberculous  lymph-gland  which 
was  shelled  out  without  diflficulty  and  the  patient  recovered. 

Like  tuberculosis,  syphilis  produces  two  kinds  of  lesions  in  the  pancreas,  the 
chronic  interstitial  and  the  gummatous;  the  former,  which  is  often  found  in  con- 
genital syphilis,  is  much  more  frequent,  but  the  two  varieties  may  coexist.  I  have 
found  no  cases  on  record  in  which  syphilomata  have  been  subjected  to  operation. 

Adenomata  of  the  pancreas  have  been  rarely  found  and  their  occurrence  has 
been  doubted.     Nicholls  ^  has  described  a  typical  case  of  adenoma  of  the  pancreas, 

'  Robson,  A.  W.  Mayo:  "The  Patholosiy  and  Surgery  of  Certain  Diseases  of  the  Pancreas," 
Lancet,  1904,  i,  p.  77.3. 

^Sendler,  Paul:  "Zur  Pathologie  und  Chirurgie  des  Pankreas,"  Deutsche  Zeitschr.  f.  Chir.. 
1896,  xliv,  S.  329. 

^  Nicholls,  Albert  Geo.:  "Simple  Adenoma  of  the  Pancreas  arising  from  an  Island  of  Langer- 
hans,"  Jour.  Med.  Research,  1902,  iii,  p.  385. 


592  SURGICAL   TREATMENT    OF   DISEASES    OF   THE    PANCREAS. 

found  at  autopsy,  and  collected  four  others  from  the  literature.  There  is  little 
likelihood  of  an  accurate  diagnosis  of  such  a  tumor  being  made  before  operation. 
Biondi  ^  successfully  removed  a  fibroadenoma  which  involved  two-thirds  of  the  head 
of  the  pancreas.     The  patient  was  well  one  and  a  half  years  after  the  operation. 

Primary  sarcoma  of  the  pancreas  is  quite  rare  and,  like  carcinoma,  is  seldom 
diagnosed  early  enough  for  successful  surgical  treatment.  There  are,  however, 
several  cases  on  record  in  which  primary  sarcomata  of  this  organ  have  been  removed 
and  the  patients  recovered. 

Trendelenburg '  removed  a  spindle-cell  sarcoma,  the  size  of  a  man's  head,  origi- 
nating in  the  tail  of  the  pancreas.  Recovery  followed.  Briggs  ^  successfully 
removed  a  spindle-cell  sarcoma  from  the  tail  of  the  pancreas,  the  growth  apparently 
originating  in  the  wall  of  a  hydatid  cyst.  Kronlein  *  removed  a  tumor,  the  size  of 
one's  fist,  from  the  head  of  the  pancreas,  the  removal  being  very  difficult.  Death 
resulted  from  gangrene  of  the  transverse  colon  due  to  interference  with  its  circula- 
tion. Microscopic  examination  showed  the  tumor  to  be  an  angiosarcoma.  Mal- 
colm ^  extirpated  a  fibrosarcoma  of  the  tail  of  the  pancreas,  but  death  resulted 
from  shock. 

Carcinoma  is  by  far  the  most  frequent  new-growth  in  the  pancreas,  and  in  over 
one-half  of  the  cases  involves  the  head  of  the  gland;  according  to  Oser,  in  65  to  70 
per  cent. 

Besides  numerous  cases  in  which  portions  of  the  pancreas,  involved  in  cancer, 
have  been  removed  along  with  the  primary  growth  in  the  stomach,  there  are  a  good 
many  cases  recorded  in  which  primary  carciriomata  of  the  pancreas  have  been 
removed  with  more  or  less  of  the  gland.  Such  cases  have  been  reported  by  Ruggi, 
Terrier,  Tricomi,  Codivilla,  Franke  and  others.  Ruggi  removed  through  the  loin 
an  adenocarcinoma  of  the  pancreas  weighing  660  grams;  the  patient  recovered 
from  the  operation,  but  died  some  months  later.  Tricomi  extirpated  almost  the 
entire  pancreas  for  adenocarcinoma;  the  patient  recovered,  although  only  a  small 
portion  of  the  tail  of  the  pancreas  was  left  behind.  In  1898  Codivilla,*'  in  a  case 
of  carcinoma  of  the  head  of  the  pancreas  which  had  involved  the  duodenum  and 
stomach,  resected  the  duodenum,  a  part  of  the  stomach,  and  the  head  of  the  pan- 
creas, completing  the  operation  by  a  cholecystenterostomy  and  gastro-enterostomy; 
the  patient  died  twenty-four  days  after  the  operation,  of  cachexia.  Franke,^  in  two 
cases  of  carcinoma  of  the  pancreas,  extirpated  a  portion  of  the  gland,  the  patients 

'  Biondi,  D.:  "Contributo  clinico  e  sperimentale  alia  chirurgia  del  pancreas,"  Clinica  Chirur- 
gica,  1896,  iv,  131. 

^Witzel,  Oscar:  "Beitrage  zur  Chirargie  der  Bauchorgane,"  Deutsche  Zeitschr.  f.  Chir., 
1886,  Bd.  xxiv,  S.  326. 

^  Briggs,  Waldo:  "Tumor  of  the  Pancreas,"  etc.,  St.  Louis  Med.  and  Surg.  Jour.,  1890, 
Iviii,  p.  154. 

*  Kronlein:  "Klinische  und  topographisch-anatomische  Beitrage  zur  Chirurgie  des  Pankreas," 
Beitrage  z.  klin.  Chir.,  1895,  Bd.  xiv',  S.  663. 

^Malcolm,  John  D.:  "Removal  of  a  Sarcomatous  Tumour  from  the  Tail  of  the  Pancreas  of 
a  Child  Four  Years  and  Eight  Months  Old,"  Lancet,  1902,  i,  p.  5S6. 

®  Villar,  Francis:  "Chirurgie  du  Pancreas,"  Paris,  1906. 

'  Franke,  Felix:  "Ueber  die  Exstirpation  der  krebsigen  Bauchspeicheldrtise,"  Arch.  f.  klin. 
Chir.,  1901,  Bd.  xliv,  S.  364. 


SOLID    TUMORS    OF   THE   PANCREAS.  593 

dying  fifteen  and  seventeen  days  respectively  after  the  operation,  one  of  secondary 
hemorrhage,  the  other  of  infection.  In  another  case  he  extirpated  the  entire  carci- 
nomatous pancreas;  this  patient  recovered  from  the  operation,  but  died  five  months 
later  of  recurrence;  there  was  only  a  slight  glycosuria,  which  lasted  from  the  fifth 
to  the  eighteenth  day,  and  there  were  no  fatty  stools. 

On  the  strength  of  this  case  Franke  thinks  the  results  of  the  animal  experiments 
of  Minkowski  and  von  Mering  are  probably  not  applicable  to  man,  and  that  in 
the  case  of  the  latter,  total  extirpation  of  the  pancreas  is  not  necessarily  fatal,  the 
functions  of  the  pancreas  sometimes  being  taken  up  by  an  accessory  pancreas  or 
else  compensated  for,  by  some  other  physiologic  process. 

As  a  rule,  solid  tumors  of  the  pancreas  are  not  diagnosed  until  symptoms  (jaun- 
dice, ascites,  etc.)  are  present  which  indicate  involvement  of  important  structures, 
hence  the  results  of  operative  interference,  up  to  the  present  time,  have  been  far 
from  satisfactory.  We  should,  therefore,  strive  to  make  an  earlier  diagnosis  and 
operate  earlier.  The  clinical  symptoms  are  at  first  obscure,  and  an  early  diagnosis 
is  extremely  difficult.  Franke  thinks  the  following  are  the  symptoms  which  might 
aid  in  an  early  diagnosis:  the  "characteristic"  epigastric  pain,  the  rapidly  progress- 
ing cachexia,  and  the  demonstration  of  a  tumor.  These  symptoms  might  lead  to  a 
probable  diagnosis  and  warrant  exploration. 

In  1906  Villar  (loc.  cit.)  collected  fifteen  cases  in  which  the  pancreas  had  been 
partially  resected  for  solid  tumors ;  of  these,  seven  recovered  from  the  operation  and 
eight  died. 

The  anterior  abdominal  incision  will  usually  be  used  for  solid  tumors  of  the 
pancreas,  but  when  the  tumor  arises  from  the  tail  of  the  gland  and  extends  out  into 
the  left  flank,  the  incision  may  be  made  in  this  region.  As  in  the  case  of  cysts,  the 
further  exposure  of  the  growth,  i.  e.,  through  the  gastrohepatic  or  gastrocolic 
omentum  or  the  transverse  mesocolon,  will  depend  upon  its  position  relative  to  the 
stomach  or  transverse  colon.  After  exposing  the  tumor  we  must  determine  whether 
an  attempt  should  be  made  to  remove  it.  If  it  is  encapsulated,  it  can  probably  be 
removed  without  great  difficulty.  If  it  involves  only  the  tail  or  a  portion  of  the 
body  of  the  pancreas  and  is  not  too  intimately  adherent  to  the  surrounding  struc- 
tures, it  can  perhaps  be  removed  with  the  involved  portion  of  the  gland.  If  there 
is  a  diffuse  involvement  of  the  organ,  including  its  head,  removal  will  be  extremely 
difficult,  and  in  most  cases  inadvisable. 

The  tumors  most  suitable  for  extirpation  are  those  which  originate  in  the  tail 
.  of  the  gland  and  are  connected  with  the  rest  of  the  gland  by  a  kind  of  pedicle  which 
it  is  only  necessary  to  ligate  and  divide.  As  a  rule,  it  is  safer  to  place  a  gauze  tam- 
pon against  exposed  pancreatic  tissue.  In  operations  involving  the  head  of  the 
pancreas,  the  common  duct,  vena  cava,  portal  vein,  and  superior  mesenteric  vessels 
should  be  carefully  avoided.  In  Kronlein's  case  injury  to  branches  of  the  latter 
was  followed  by  gangrene  of  the  colon. 

In  most  of  the  cases  of  malignant  growths  of  the  pancreas  which  we  see,  radical 
operations  are  inadvisable  and  we  sometimes  resort  to  palliative  measures.  Chole- 
voL.  II — 38 


594  SURGICAL    TREATMENT    OF   DISEASES    OF   THE    PAXCREAS. 

cystostomy  and  cholecystenterostomy  for  the  relief  of  the  jaundice  are,  however, 
attended  by  a  high  mortahty  and,  when  successful,  prolong  the  life  of  the  patient 
so  little  that  these  operations  should  seldom  be  done  unless  the  jaundice  (itching, 
etc.)  is  very  annoying  to  the  patient.  The  chief  argument  in  their  favor  is  that 
chronic  pancreatitis,  which  can  sometimes  hardly  be  distinguished  from  cancer  of 
the  pancreas,  is  greatly  benefited  by  these  procedures.  Death  following  them  is 
often  the  result  of  post-operative  hemorrhage  due  to  the  jaundice. 

The  following  are  the  statistics  of  Mayo  Robson:  Of  fifteen  cases  in  which 
he  performed  cholecystostomy  for  carcinoma  of  the  pancreas  with  jaundice,  eight 
recovered  from  the  operation,  the  longest  sur\'ival  being  eight  months,  but  the  aver- 
age survival  was  about  four  months;  of  the  six  cholecystenterostomies,  two  recov- 
ered and  the  duration  of  life  was  only  a  few  weeks;  of  six  exploratory  laparot- 
omies, two  died. 

In  a  few"  rare  instances  the  growth  in  the  head  of  the  pancreas  has  so  constricted 
the  duodenum  that  it  has  been  considered  advisable  to  perform  a  gastro-enterostomy. 

Pancreatic  Fistulae. — Fistulse  which  result  from  the  drainage  of  wounds  or 
cysts  of  the  pancreas  are  very  annoying,  owing  to  their  persistence  and  to  the 
excoriation  of  the  skin  produced  by  the  pancreatic  secretion.  ]Many  cases  are  on 
record  in  which  they  have  lasted  a  year  or  more  and  some  have  even  been  permanent. 

The  excoriation  of  the  skin  is  often  distressing  in  spite  of  everything  that  is 
done  to  combat  it,  such  as  the  application  of  various  ointments,  lanolin,  etc.  Bur- 
meister  ^  has  applied  suction-pump  drainage  to  such  fistulse  and  claims  to  have 
obtained  excellent  results,  the  skin  being  thus  kept  dry  and  intact  and  the  healing 
of  the  fistula  hastened.  This  method  is  also  recommended  by  Heineke.^  The  best 
way  to  hasten  healing,  however,  is  by  the  administration  of  a  carbohydrate-free  diet, 
as  advised  by  Wohlgemuth,^  who  has  shown  that  the  amount  of  pancreatic  secretion 
depends  upon  the  composition  of  the  diet:  with  purely  fatty  diet  the  secretion  is 
minimal,  with  proteid  diet  somewhat  more,  and  with  carbohydrate  diet  is  considera- 
bly increased.  Acids  stimulate  and  alkalies  retard  the  secretion.  For  such  cases 
Wohlgemuth  recommends  a  carbohydrate-free  diet  with  frequent  small  doses  of 
sodium  bicarbonate. 

In  a  case  of  Karewski*  the  fistula  was  thus  quickly  cured,  and  Heineke  reports 
a  case  in  which  the  fistula  closed  three  days  after  the  treatment  was  instituted. 

Sometimes  curettage  or  cauterization  of  a  pancreatic  fistula  will  cause  it  to  heal. 
These  methods  are,  however,  not  totally  devoid  of  danger,  as  cases  of  fatal  hemor- 
rhage have  been  known  to  follow  their  use.  If  the  sinus  persists  after  all  of  the 
above  mentioned  expedients  have  been  tried,  it  may  be  advisable  to  excise  it  or 
institute  posterior  drainage. 

^  Burmeister,  R.:  "Ueber  SaucpumpendrainaKe  bei  Pankreascyste,"  Arch.  f.  klin.  Chir., 
Bd.  Ivi,  S.  183. 

2  Heineke,  H.:  "Zur  Behandlune;  der  Pankreasfisteln,"  Centralbl.  f.  Chir.,  1907,  Bd.  xxxiv, 
S.  265. 

^Wohlgemuth,  .!.:  "Untersuchungen  iiber  das  Pankreas  des  Menschen,"  BerL  khn.  Woch- 
enschr.,  1907,  xliv,  Nr.  2,  S.  47. 

^Karewski,  F.:  "Ueber  isolierte  subkutane  Verletzungen  des  Pankreas  und  deren  Behand- 
lung,"  BerL  klin.  Wochenschr..  1907,  xliv,  Nr.  7,  S.  187. 


CHAPTER  XXXVII. 

OPERATIONS  UPON  THE  SPLEEN. 
By  Howard  A.  Kelly,  M.D. 

Although  the  spleen  is  not  often  the  subject  of  operation  in  the  practice  of  any 
one  surgeon,  the  total  number  of  operations  upon  this  organ  has  been  considerable. 
The  variety  of  indications  for  splenic  operations,  of  a  more  or  less  radical  nature, 
must  surprise  any  one  who  investigates  the  subject  carefully  for  the  first  time. 
They  have  been  done  for  the  following  conditions:  (1)  Displaced  or  wander- 
ing spleen;  (2)  torsion  of  pedicle;  (3)  simple  hypertrophy;  (4)  malarial  hyper- 
trophy; (5)  splenomegaly  with  anemia,  or  associated  with  cirrhosis  of  liver  and 
ascites,  called  Banti's  disease;  (6)  chronic  enlargement  in  infancy;  (7)  traumata, 
such  as  stab  wound,  gunshot  wound,  laceration  from  contusion;  (8)  blood  cyst; 
(9)  simple  cyst;  (10)  echinococcus  cyst;  (11)  abscess;  (12)  tuberculosis;  (13)  sar- 
coma;  (14)  syphilis;   (15)  amyloid  degeneration;   (16)  angioma;   (17)  leukemia. 

Let  me  say  emphatically  at  the  outset  that  it  is  now  universally  agreed,  after 
numerous  distressing  failures  following  the  attempts  of  enterprising  surgeons,  that 
leukemia  should  never  be  treated  by  splenectomy.  Such  patients,  if  operated  upon, 
almost  always  die  immediately,  and  of  the  few  which  have  survived  the  operation, 
not  one  has  been  cured  of  the  disease. 

Sometimes  the  conditions  to  which  reference  has  been  made  appear  in  com- 
bination. Sutton,  in  1898,  described  a  wandering  tubercular  spleen,  and  numerous 
cases  of  displaced  hypertrophied  spleens  are  on  record. 

Many  cases  of  hypertrophy  of  the  spleen  associated  with  twisted  pedicle  have 
also  been  recorded.  J.  C.  Webster^  describes  one  of  the  most  interesting  of  these, 
in  which  the  spleen  weighed  28  ounces. 

Traumatic  injuries  to  the  spleen,  such  as  laceration,  gunshot  wound,  etc.,  are 
most  frequently  associated  with  other  and,  as  a  rule,  far  graver  injuries  to  the  ab- 
dominal viscera.  The  spleen  may  even  in  such  cases  escape  through  the  wound  and 
remain  for  a  long  time  outside  the  abdominal  cavity.  This  actually  occurred  in 
one  extraordinary  Indian  case,  where  the  patient  traveled  about  for  weeks  with  a 
fungating  mass  protruding  under  the  left  ribs.  Other  complications  arise  from  the 
combination  of  a  splenic  affection  with  disease  of  some  other  organ,  as,  for  example, 
ovarian  cyst  with  displaced  spleen.     Such  a  case  was  recorded  by  Pean-  in  1869. 

Almost  all  important  references  to  the  literature  of  the  spleen  are  to  be  found 
in  an  admirable  historical  review  by  B.  ]\L  Ricketts,  of  Cincinnati,  entitled  "Surgery 

HVebster,  J.  C:  "A  Case  of  Successful  Removal  of  an  Enlarged  Spleen,"  Jour.  Amer.  Med. 
Assoc,  1903,  xl,  887. 

^Pean,  J.:  "Ovariotomie  et  splenotomie,"  Paris,  1869. 

595 


596  OPERATIONS    UPON   THE    SPLEEN. 

of  the  Prostate,  Pancreas,  Diaphragm,  Spleen,  Thyroid,  and  Hydrocephahis, " 
Cincinnati,  1904,  from  which  nothing  of  value  seems  to  have  been  omitted. 

Before  taking  up  particular  ailments,  and  discussing  their  respective  surgical 
indications,  it  will  be  well  to  review,  categorically,  the  various  surgical  procedures 
which  have  been  employed  upon  this  organ. 

These  are:  simple  ligation  of  one  of  the  splenic  vessels;  this  has  been  success- 
fully done  by  Wyman,^  who  in  1889  ligated  the  splenic  artery  in  an  attempt  to  cure 
a  hypertrophy. 

Balacescu,^  working  under  Jonnesco,  found  in  experimenting  upon  animals 
that  when  all  the  vessels  going  to  the  spleen  were  ligated  en  masse,  gangrene 
sometimes  occurred,  followed  by  death.  "When  the  animals  survived,  the  spleen 
became  atrophied.  If  only  an  artery  or  the  vein  was  ligated,  atrophy  took  place, 
but  slowly.  The  total  removal  of  the  spleen  has  been  done  repeatedly  by  operators 
of  eminence  for  displacement  of  the  organ,  for  hypertrophy,  and  for  torsion  of  its 
pedicle,  as  well  as  for  trauma. 

The  spleen  has  been  sutured  in  case  of  rupture  of  its  capsule,  hydatids  have 
been  aspirated,  and  Fowler's  solution  of  arsenic  has  been  injected  into  the  spleen. 
Ergot  has  been  injected  for  hypertrophy.  Abscesses  have  been  opened,  evacuated, 
and  drained.     Cysts  have  also  been  opened  and  drained. 

The  spleen  has  been  suspended  by  cutting  a  slit  into  the  peritoneum  and  drawing 
the  organ  more  or  less  completely  out  of  the  peritoneum  under  the  abdominal  wall. 

Partial  excision  has  been  practised  by  Jordan^  on  dogs,  twenty-one  out  of 
twenty-two  cases  recovering. 

The  movable  spleen  has  been  fixed  hj  suture  (splenopexy). 

The  indications  for  operating  on  the  spleen  are  manifold,  arising  when  the  spleen 
alone  is  the  source  of  trouble,  as  in  simple  hypertrophy,  movable  spleen,  malignant 
disease,  echinococcus  cysts,  etc. ;  or  in  certain  general  diseases  which  may  occasion 
splenic  changes  demanding  operative  interference,  such  as  malaria,  or  as  Banti's 
disease. 

Duplay  and  Reclus^  divide  the  indications  for  surgical  treatment  of  the  spleen 
into  the  following  groups:  (1)  traumata,  (2)  displacements,  (3)  parasitic  affections, 
(4)  neoplasms,  including  in  the  last  all  the  hypertrophies;  while  Jordan,^  after  a 
careful  consideration  of  splenic  operations  in  general,  draws  the  following  conclu- 
sions: 

1.  The  function  of  the  spleen,  as  practical  experience  shows,  is  readily  performed 
by  other  organs,  and  it  can,  therefore,  be  easily  spared. 

2.  Hence  it  may  be  removed  without  serious  results,  especially  when  diseased. 

MVvman,  H.  C:  "On  Ligation  of  Splenic  Artery  for  Cure  of  Hypertrophy  of  Spleen,"  Jour. 
Amer.  Med.  Assoc,  1889,  xii,  76-4. 

^Balacescu:  "Die  Ligatur  der  Gafiisse  der  Milz  beim  Thier,"  Miinch.  med.  Wochenschr., 
1901,  xlviii,  1378. 

2  Jordan,  N.  M.:  "Conservative  Surgery  of  the  Spleen,"  Lancet,  1898,  i,  208. 

^Duplay,  S.,  and  Reclus,  P.:  Traite  de  chir.,  Paris,  1898,  vi,  942. 

5  Jordan,  M. :  "Die  Exstirpation  der  Milz,"  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1903,  xi,  452. 


GENERAL    STATISTICS.  597 

3.  Splenectomy  is  thus  justifiable  on  purely  relative  indications. 

4.  The  extirpation  of  the  spleen  offers  the  most  favorable  chances  for  cure  when 
the  disease  is  purely  local.  If,  on  the  contrary,  the  splenic  affection  is  only  the  local 
expression  of  a  constitutional  disorder,  extirpation  offers  no  hope,  is  dangerous, 
and  ought  not  to  be  attempted. 

5.  In  the  present  state  of  surgery,  splenectomy  for  a  movable  spleen  is  almost 
without  danger,  though  adhesions  may  offer  a  serious  complication,  and  extensive 
adhesions  may  render  the  operation  impossible. 

6.  The  choice  of  an  incision,  whether  median,  lateral,  vertical,  or  horizontal, 
or  a  combination  of  any  of  these,  must  be  regulated  by  the  special  conditions  in 
the  case  as  well  as  by  the  form  of  the  body  and  the  size,  position,  and  form  of  the 
tumor. 

7.  Statistics  show  that  women  are  much  more  liable  to  surgical  affections  of  the 
spleen  than  men,  those  arising  from  traumata  excepted. 

General  Statistics. — The  best  discussion  relative  to  the  surgery  of  the  spleen 
up  to  1894  is  the  paper  of  O.  Vulpius.^  He  reckoned  the  percentage  of  recovery 
after  laparo-splenectomy  at  that  time  as  50.  Of  leukemic  spleen,  he  says  that  out 
of  twenty-eight  operations,  death  occurred  promptly  in  twenty-five,  and  only  one 
case  was  cured;  even  in  this  one  instance  the  diagnosis  was  doubtful. 

In  the  year  1900,  Bessel  Hagen^  collected  360  cases  of  splenectomy,  with  222 
recoveries  and  138  deaths,  a  mortality  of  38  per  cent.  The  percentage  of  mortality 
prior  to  1890  was  42,  while  during  the  decennium  ending  1900  it  dropped  to  19. 
Such  general  statistics  as  these  are  of  httle  value,  however,  as  the  operation  may  be 
one  of  the  severest  in  surgery  or  one  of  the  simplest,  and  it  is  usually  possible  to 
predicate  the  amount  of  danger  incurred  in  the  particular  case.  The  most  impor- 
tant surgical  fact  demonstrated  by  experience  is  that  the  economy  of  the  body  is 
perfectly  performed  without  the  spleen,  suffering  from  its  loss  in  no  demonstrable 
manner.  In  two  of  my  own  cases  seven  years  have  elapsed  since  splenectomy  was 
performed  and  the  patients  both  write  that  they  are  in  the  best  of  health.  Both 
have  borne  children. 

The  removal  of  a  freely  movable  spleen  with  a  long  pedicle  is  attended  by  no 
more  difficulty  and  danger  than  an  uncomplicated  ovariotomy;  on  the  other  hand, 
when  the  organ  is  fixed,  the  dense  vascular  adhesions,  which  almost  always  accom- 
pany  tumors,  make  the  operation  extremely  difficult  and  lead  to  high  mortality. 
Whether  the  leukocytosis  observed  for  a  few  days  after  a  splenectomy  is  really  due 
to  the  removal  of  the  organ  is  a  matter  not  entirely  beyond  question.  Jordan  re- 
marks that  the  important  practical  point  is  the  fact  that  disturbances  in  the  blood 
system  are  only  transitory,  and  never  attended  by  any  serious  consequences.  He 
further  quotes  three  cases  (Savoir,  Fritsch,  and  Schwartz)  in  which  the  spleen  was 
removed  in  the  sixth,  in  the  first,  and  in  the  fifth  months  of  pregnancy  respectively 
without  disturbing  the  patient's  condition. 

iVulpius,  O.:  "Beitriige  zur  Chir.  u.  Phys.  der  Milz,"  Beitr.  z.  klin.  Chir.,  1894.  xi.  633. 
2  Bessel  Hagen,  F.:  "Ein  Beitrag  zur  Milzchirurgie,"  Arch.  f.  klin.  Chir.,  1900,  Ixii.  188. 


-598 


OPERATIONS    UPON   THE    SPLEEN. 


Contraindications  to  Operation. — Among  the  contraindications  to  operations 
upon  the  spleen,  Laurent^  cites  the  foUowing  grave  conditions  in  other  organs :  INIul- 
tiple  hydatid  cysts;  amyloid  degenerations;  leukemia;  pseudo-leukemic  hyper- 
trophy; general  comphcations :  tuberculosis,  syphilis,  cardiopathy,  pneumono- 
pathy;  tumefaction  secondary  to  cirrhosis  of  the  hver;  splenic  metastases,  pyemia, 
or  maHgnant  disease.  In  cachexia,  with  grave  anemia,  general  edema,  marked 
tendency  to  hemorrhage,  and  extensive  adhesions,  the  ablation  of  a  hypertrophied 
malarial  spleen  is  contraindicated. 

Contraindications  to  operation  are  also  found  in  the  secondary  splenic  tumors, 

arising,  for  example,  when  enlargement 
of  the  spleen  follows  cirrhosis  of  the 
liver;  in  cases  of  amyloid  degeneration 
or  tuberculosis  elsewhere;  in  syphilis; 
and  where  there  is  portal  obstruction. 

A  pulsating  splenic  tumor  is  not  a 
suitable  object  for  a  radical  operation, 
as  this  disease  is  usually  associated 
either  with  acute  infectious  diseases  or 
hypertrophy  of  the  left  ventricle,  and 
especially  with  aortic  insufficiency. 

In  children  there  is  a  form  of  anemia 
associated  with  splenic  tumor  which 
Morse ^  calls  "secondary  anemia  with 
splenic  tumor. "  In  an  interesting  case 
of  a  baby  in  Morse's  hands,  the  child 
had  rickets  and  enlarged  spleen  with 
anemia.  A  nutritive  diet  of  milk  and 
beef-juice,  together  with  maltine,  oil, 
and  syrup  of  the  iodid  of  iron,  soon 
brought  about  remarkable  improve- 
ment, and  reduced  the  size  of  the  spleen, 
which  extended  to  the  right  of  the  um- 
bilicus, so  far  as  the  anterior  superior 
spine,  and  back  into  the  loin,  to  such  a 
marked  degree  that  it  could  not  be  felt. 
This  is  a  condition  which  has  often  been  spoken  of  as  "anemia  infantum,"  or 
"anemia  infantum  pseudo-leukemia."  I  mention  this  condition  thus  carefully  as 
a  warning  to  the  surgeon.     (See  Fig.  776.) 

Diagnosis. — With  the  exception  of  simple  excessive  mobility  and  traumata  of 
the  spleen,  all  the  conditions  indicating  operation  are  associated  with  more  or  less 

^Laurent,  O.:    "  Anatomie  Clinique  et  Technique  Operatoire,"  Paris,  1906,  p.  629. 
^  Morse,  J.  L.:  "Chronic  Enlargement  of  the  Spleen  in  Infancy,"  Ann.  Gyn.  and  Ped.,  1900, 
xiv,  153. 


Fig.  776. — Morse's  Case  of  Infantile  Hyper- 
trophy OF  THE  Spleen  with  Anemia  Cured 
BY  Medicinal  Hygienic  Treatment. 

A,  Spleen;   B,  lower  border  of  liver;    C,  costal  border. 


DIAGNOSIS. 


599 


hypertrophy  of  the  organ.  The  movable  spleen  is  best  recognized  by  a  peculiar 
softness,  a  distinctive  notch,  and  a  wide  range  of  mobility,  associated  with  the  ab- 
sence of  the  normal  dullness  on  percussion  in  the  left  lower  chest,  and  it  is  most  apt 
to  be  mistaken  for  a  movable  left  kidney  or  an  ovarian  tumor.  The  distinction 
between  spleen  and  kidney  is  easily  made  by  introducing  a  renal  catheter  and  in- 
jecting the  kidney  with  enough  fluid  to  produce  a  mild  renal  colic,  which  will  be 
referred  to  the  lumbar  region  and  not  to  the  organ  under  touch  beneath  the  abdom- 
inal wall.  A  normal  pregnancy  has  been  mistaken  for  a  hypertrophied  movable 
spleen  in  my  own  clinic,  though  fortunately  no  operation  was  done. 

Careful  pelvic  examination  under  an  anesthetic  ought  to  exclude  uterus,  tubes, 
and  ovaries  from  participation  in  the  disease,  while  the  skiagraph  and  the  renal 
catheter  should  distinguish  renal 
tumors,  thus  leading  up  to  the 
spleen  by  a  simple  process  of  exclu- 
sion. In  the  above  consideration 
the  spleen  alone  has  been  consid- 
ered in  association  with  its  abnor- 
mality. AYhen,  however,  the  affected 
spleen  is  associated  with  a  blood 
disease,  as  malaria  or  leukemia,  a 
blood  examination  both  suggests 
and  confirms  diagnosis. 

In  trauma  the  diagnosis  may  be 
made  when  the  injury  is  in  the 
splenic  region,  particularly  when 
the  spleen  is  enlarged.  As  a  rule, 
however,  the  signs  are  merely  those 
of  internal  hemorrhage  and  col- 
lapse, and  it  is  not  possible  to  pre- 
dicate just  what  organ  or  organs  are 
involved,  whereas  in  splenomegaly 
the  diagnosis  is  not  so  difficult,  as 

the  characteristic  form  and  notch  are  retained.  Great  difficulty,  however,  may  arise 
when  the  enlarged  organ  becomes  fixed  at  a  point  remote  from  its  normal  habitat. 

It  is  well  that  the  surgeon  should  be  on  his  guard  and  not  confuse  certain  rare 
cases  of  hyperglobulia  and  splenic  tumor  with  other  diseases,  but  this  peculiar 
disease  shows  a  combination  of  the  following  symptoms:  cyanosis,  tachycardia, 
dyspnea,  albuminuria,  sometimes  enlargement  of  the  liver,  and  enlargement  of  the 
spleen,  together  with  an  increase  in  the  number  of  red  blood-cells,  called  by  Wm. 
Osler^  "  chronic  polycythemia  with  cyanosis  and  enlarged  spleen  " ;  see  also  P.  Preiss.- 


FiG.  777. — Splenic  Tumor  (a)  in  the  Right  Iliac  Fossa. 
Removed  by  J.  C.  Webster.      6,  Site  of  incision  four  years 
previously. 


1  Osier,  W. 
^Preiss,  P. 
xiii,  287. 


"Prin.  and  Prac.  Med.,"  1905,  p.  762. 

"Hyperglobulia  und  Milztumor,"  Mitth.  a.  d.  Grenzg.  der  Med.  u.  Chir.,   1904, 


600  OPERATIONS    UPON    THE    SPLEEN. 

Not  infrequently  the  operation  upon  the  spleen  is  wholly  unpremeditated,  the 
diagnosis  beforehand  having  been  that  of  a  fibroid  tumor  of  the  uterus,  an  ovarian 
tumor,  or  perhaps  a  misplaced  kidney.  In  one  of  my  own  splenectomies  the 
movable  pelvic  tumor  was  supposed  to  be  ovarian  until  the  abdomen  was  opened. 
In  J.  C.  Webster's  case  (see  Fig.  777)  the  prominence  caused  by  the  enlarged  spleen 
lay  in  the  iliac  fossa,  and  the  clinical  symptoms  strongly  suggested  an  intermittent 
hydronephrosis;  indeed,  the  abdomen  had  already  been  incised  four  years  before, 
and  the  surgeon  at  that  time  declared  that  he  found  an  inoperable  right  renal  tumor. 

Bland-Sutton,^  in  a  thoughtful  article  on  wandering  spleen,  cites  a  case,  showing 
occasional  difficulties  in  diagnosis.  A  girl,  fourteen  years  of  age,  had  a  tumor 
floating  in  the  intestines,  where  it  lay  obliquely  across  the  left  side  of  the  abdomen, 
its  upper  end  reaching  the  left  hypochondrium.  Nothing  abnormal  was  felt  on 
pelvic  examination,  and  the  splenic  area  was  resonant.  The  tumor  had  the 
shape  and  notched  border  of  a  spleen,  leading  to  a  diagnosis  of  wandering  spleen; 
therefore  an  incision  was  made  in  the  left  semilunar  line  to  remove  it,  when  a  multi- 
locular  ovarian  cyst  was  found,  partly  collapsed  from  a  rupture  of  its  largest  loculus. 
The  secondary  cyst  gave  rise  to  the  sensation  of  splenic  notches. 

Korte,  cited  by  Bland-Sutton,  had  a  case  of  wandering  spleen  which  he  regarded 
as  a  wandering  kidney,  and  when  signs  of  internal  strangulation  arose,  he  punctured 
the  tumor;  nothing  but  blood  escaped,  however,  and  the  patient  died  with  signs 
of  intestinal  obstruction  and  peritonitis.  A  post  mortem  then  disclosed  the  spleen 
lodged  in  the  pelvis  and  obstructing  a  loop  of  intestine. 

Splenectomy  is  the  typical  operation,  inasmuch  as  the  spleen  can  readily  be  re- 
moved, the  economy  suffering  no  detriment  from  its  loss;  while,  on  the  other  hand, 
conservative  operations  involving  a  resection,  or  a  suture  either  for  injuries  or  for 
the  purpose  of  suspension,  are  all,  as  a  rule,  more  troublesome  and  more  dangerous 
than  total  extirpation.  I  would  not,  however,  utterly  reject  all  conservative  methods, 
as  they  are  proper  from  time  to  time  in  peculiarly  suitable  cases. 

SPLENECTOMY. 

Technic. — The  general  principles  of  splenectomy  are:  first,  the  incision,  which 
may  be  made  along  the  border  of  the  ribs,  or  as  a  median  laparotomy  in  cases  of 
hypertrophied  spleen,  or  of  exploration  for  abdominal  trauma.  A  convenient  inci- 
sion may  also  be  made  in  the  left  semilunar  line,  over  the  most  prominent  part  of  the 
spleen.  If  the  opening  secured  in  this  way  is  not  large  enough,  it  can  be  made  much 
larger  by  carrying  a  horizontal  incision  from  the  vertical  one  down  into  the  left  flank. 
On  the  whole,  the  semilunar  incision  is  to  be  preferred. 

The  next  step,  with  a  movable  spleen,  is  to  bring  it  outside  the  body  and  protect 
the  adjacent  intestines,  while  exposing  its  pedicle  for  ligation.  If  the  spleen  is  ad- 
herent, the  adhesions  should  first  be  separated,  if  they  are  not  too  vascular,  and  the 
organ  should  then  be  delivered  from  the  abdomen.  In  case  of  adherent  spleen  in 
1  Bland-Sutton,  J.:  "Remarks  on  Wandering  Spleens,"  Brit.  Med.  Jour.,  1897,  132. 


SPLENECTOMY. 


601 


which  the  pedicle  is  accessible,  the  vessels  may  first  be  doubly  tied  and  then  cut 
between  the  ligatures,  the  adhesions  being  easily  dealt  with.  When  these  adhesions 
are  numerous  and  excessively  vascular,  it  will  often  be  wise  to  desist  from  proceeding 
with  the  operation,  for  death  from  uncontrollable  hemorrhage  can  easily  occur. 

The  splenic  vessels  can  often  be  best  exposed,  in  the  case  of  an  enlarged  spleen 
still  within  the  abdomen,  by  rotating  the  organ  outward  and  at  the  same  time  draw- 
ing the  stomach  inward. 

Ligation  of  the  Pedicle. — Where  there  is  a  non-vascular  fold  of  peritoneum  above 
the  vessel,  it  may  be  cut  through;  when  the  artery  stands  out  prominently,  it  must 
first  of  all  be  ligated.     In  general,  the  first  plan  is  to  hgate  the  pedicle  by  a  series  of 


Stom 


Bursa- 
omenta  lis 


^ilus 


PJirenico- 


Fig.  778. — Horizontal  Section  through  Splenic  Region  Viewed  from  Below. 
The  stomach  is  drawn  to  the  right  in  order  to  stretch  the  gastrosplenic  ligament. 

interlocking  .silk  ligatures,  passing  them  as  far  away  from  the  spleen  as  possible  so 
as  to  avoid  any  risk  of  their  slipping  after  the  removal  of  the  organ.  After  applying 
the  ligatures,  the  vessels  may  be  controlled  on  the  side  of  the  spleen  by  strong  artery 
forceps,  after  which  they  are  divided  at  a  good  safe  distance  from  the  ligatures,  and 
the  organ  removed. 

As  a  next  step  a  careful  examination  of  the  pedicle  should  be  made  to  make  sure 
that  hemorrhage  is  impos.sible.  If  there  is  any  doubt  of  the  thoroughness  of  the 
hgation  or  the  security  of  the  ligatures,  it  is  a  safer  plan  to  pick  up  the  ends  of  the 
vessels  individuallv  and  to  tie  them  with  strong  catgut. 


602 


OPERATIONS    UPON   THE   SPLEEN. 


Examination  of  the  pedicle  of  the  spleen  is  always  necessary  before  ligation, 
as  the  tail  of  the  pancreas  is  often  drawn  out  so  as  to  form  a  part  of  it.  Engel 
has  proposed  twisting  the  pedicle  in  the  abdomen  so  as  to  bring  about  an  atrophy, 
which  is  a  suggestion  hardly  likely  to  find  favor  in  these  days. 


Tr^ns  ver\    \\S e 


Jristru merit  /'n 
o/nerit^l  bursa. 


Fig.  ^9. — Splenectomy. 

First  step  in  a  spleuectomy  which  may  necessitate  tying  the  enlarged  vasa  brevia  between  the  spleen  and  the 

stomach.     The  vessels  may  be  tied  and  gastrosplenic  ligaments  incised  as  shown  in  the  dotted  line, 


Post-operative  Sequelae.— The  commonest  sequel  to  splenectomy  is,  fortu- 
nately, an  uninterrupted  convalescence  without  any  discernible  change  in  the 
patient. 

The  spleen  has  been  described  as  a  building  place  for  both  red  and  white  blood- 


SPLENECTOMY. 


603 


cells  and  also  as  the  normal  place  for  destruction  of  red  blood-cells,  but  whatever 
may  be  the  physiology,  its  function  or  functions  are  easily  assumed  by  other  organs. 
Animal  experiments  seem  to  point  to  the  bone-marrow  and  lymph-glands  as  vicars 
for  the  spleen,  and  in  splenectomized  animals,  hyperemias  of  the  bone-marrow  have 


ya5a  brey/u 


vasa  brevjd 
f 


'Left  gastro- 
epiploic vein 
[a^d  artery 


Fig.  780. — Splenectomy. 
After  severing  the  gastrosplenic  ligament  the  large  splenic  vessels  are  exposed.     The  pedicle  is  formed  and 
exposed  for  ligation  by  lifting  the  spleen  well  out  of  its  bed  and  out  of  the  abdomen.     One  ought  to  avoid  the 
left  gastro-epiploic  vein  and  artery  if  possible. 

been  observed.     Hartley^  has  described  in  three  cases  a  transitory  hypertrophy  of 
the  thyroid. 

It  has  been  frequently  observed  and  reported  that  a  general  enlargement  of  the 
lymphatics  takes  place  after  splenectomy,  while  the  cervical  glands  and  the  tonsils 
,seem  to  be  affected  most  fre^iuendy.      Irregular  rises  in  temperature  have  been 
'  Hartley:  "Splenectomy,"  Med.  News,  1898,  Ixxii,  417. 


604  OPERATIONS    UPON   THE   SPLEEN. 

reported  by  Bond  and  others,  and  in  a  number  of  cases  infection  of  the  pedicle  has 
occurred,  leading  to  severe  pain  in  the  left  hypochondrium  as  late  as  two  weeks  after 
operation.  This,  again,  has  been  followed  by  a  localized  accumulation  of  pus  dis- 
charged through  the  abdominal  wall  or  into  the  bowel,  and  in  one  instance  the  pedicle 
ligatures  themselves  were  coughed  up  by  the  patient.  Changes  in  the  blood  are 
decidedly  inconstant,  and  in  many  cases  would  seem  to  depend  on  other  conditions 
than  the  spleen's  removal.  The  commonest  change  observed  has  been  a  decrease 
in  the  number  of  red  blood-cells  and  an  increase  in  the  number  of  the  white,  this 
change  lasting,  on  an  average,  about  two  months.  It  seems  to  occur  fairly  con- 
stantly in  dogs.  Bond,^  in  two  cases,  observed  a  great  increase  in  the  number  of 
red  blood-cells,  which  he  explained  by  a  decreased  destruction  of  them. 

In  two  of  my  own  cases  of  enlarged  movable  spleen,  where  careful  blood 
studies  were  made  before  and  after  operation,  no  abnormal  constituents  were  found 
in  the  blood,  the  relative  proportion  of  the  white  cells  being  uninfluenced  by  removal 
of  the  spleen;  and  in  neither  case  was  any  diminution  of  the  red  cells  noted,  though 
in  one  there  was  a  slight  increase  in  the  number  of  white  blood-cells,  which  dis- 
appeared within  a  month. 

The  tabulated  list  at  the  beginning  of  the  chapter  shows  in  what  conditions 
splenectomies  have  been  done ;  the  long  list  of  such  conditions  and  the  considerable 
number  of  positive  contraindications  to  operation  which  have  been  adduced  from 
them  suggest  at  once  both  the  difficulty  and  the  importance  of  an  accurate  differ- 
ential diagnosis.  No  operator  should  remove  a  spleen  without  a  previous  general 
and  searching  examination;  while  a  knowledge  of  the  blood  findings  is  especially 
imperative.  An  extensive  consideration  of  these  conditions  is  manifestly  impossible 
here,  where  a  bare  pointing  out  of  certain  salient  features  and  an  exhibition  of 
operative  indications  and  results  is  all  that  can  be  indicated.  The  reader,  however, 
is  urged  to  consult  standard  medical  works  for  further  information.  Unless  the 
differential  diagnosis  and  clinical  courses  of  the  various  splenomegalies  are  under- 
stood and  constantly  kept  in  mind,  surgery  is  a  hazardous  procedure,  as  a  radical 
operation  may  easily  be  productive  of  great  harm. 

In  considering  the  separate  subjects,  the  order  adopted  in  the  table  at  the 
beginning  of  the  chapter  will  be  adhered  to. 

DISPLACED   OR  WANDERING  SPLEEN,  WITH   OR   WITHOUT   TORSION  OF  THE 

PEDICLE. 

Neither  a  fixed  displacement  nor  an  abnormal  mobility  of  the  spleen  are  condi- 
tions of  common  occurrence,  and  no  one  observer  has  reported  any  considerable 
series  of  cases.  Nevertheless,  there  are  few  surgeons  of  large  experience  who  have 
not  met  with  and  treated  one  or  more,  so  that  the  total  number  reported  is  larger 
than  would  be  supposed. 

Fixed  ectopia  is  secondary  to  changes  which  serve  to  anchor  an  abnormally 

^Bond,  C.  J.:  "Remarks  on  a  Case  of  Splenectomy,  with  Observations  on  the  Condition  of 
the  Blood  before  and  after  Operation,"  Lancet,  1896,  i,  1207. 


DISPLACED    OR   WANDERING   SPLEEN.  605 

mobile  spleen  in  its  abnormal  situation,  and  for  this  reason  it  is  best  regarded  as  a 
complication  of  wandering  spleen.     Such  a  condition  is  never  congenital. 

Normally,  the  spleen  is  not  a  freely  movable  organ,  this  fact  rendering  all  the 
more  striking  by  contrast  the  extreme  mobility  which  it  may  acquire  in  these  cases, 
for  there  is  scarcely  a  region  of  the  abdomen  where  it  has  not  been  found.  Even 
the  true  pelvis  seems  to  be  a  common  site.  In  one  of  my  own  cases  at  the  Johns 
Hopkins  Hospital  (Gyn.  No.  7193)  it  was  firmly  wedged  in  the  true  pelvis,  and  was 
mistaken  for  a  large  myoma  springing  from  the  posterior  wall  of  the  uterus.  In 
another  case  (Gyn.  No.  9737)  it  was  twisted  and  became  fixed  in  the  region  of  the 
cecum,  occasioning  symptoms  of  an  ectopic  right  kidney. 

The  unusual  enlargement  which  most  of  these  spleens  show  may  be  due  to  a 
true  hypertrophy,  but  is  most  frequently  dependent  on  venous  engorgement.  The 
following  case  (Bland-Sutton^)  well  illustrates  how  greatly  simple  engorgement 
influences  the  size  of  this  organ : 

"In  a  young  girl,  laparotomy  disclosed  an  enormous  spleen,  reaching  all  the 
way  from  the  diaphragm  to  the  top  of  the  uterus.  On  delivering  this  organ  and 
surrounding  it  with  cool  gauzes,  Sutton  saw  it  contract  to  one-third  of  its  size  when 
first  exposed." 

The  commonest  complication  of  a  wandering  spleen  is  a  twisted  pedicle.  The 
ease  with  which  a  twist  may  take  place  is  readily  comprehended,  as  also  are  its 
results.  When  the  rotation  occurs  gradually,  an  atrophy  of  the  organ  may  follow; 
on  the  other  hand,  if  the  circulation  is  cut  off  at  once,  gangrene  takes  place.  After 
twisting,  perisplenitis  is  constantly  found  and  the  organ  almost  always  becomes  ad- 
herent. Owing  to  its  poor  circulation  abscess  may  develop,  as  in  a  case  in  the  hands' 
of  my  colleague,  W.  S.  Halsted,  which  is  reported  by  Osler.^  Among  other  compli- 
cations of  mobile  spleen,  tuberculosis  has  been  noted;  Llobet^  reports  the  occur- 
rence of  a  cancer  of  the  pedicle.  The  cause  of  the  mobility  is  not  clear;  many  of  the 
ingenious  explanations  offered  for  movable  kidney  have  been  advanced  here.  It  is 
more  frequent  in  women  than  in  men;  the  spleen  is  enlarged;  and  the  patients 
are  usually  thin;    these  are  the  known  factors. 

It  has  been  noted  that  movable  spleen  may  cause  few  or  no  symptoms;  a  ma- 
jority of  cases,  however,  complain  of  the  discomfort  arising  from  the  vagrant 
organ  and  suffer  from  marked  digestive  disturbances,  the  commonest  site  of  the 
pain  being  in  the  left  epigastric  region,  and  its  nature  a  chronic  ache,  but  neither 
location  nor  character  is  constant.  In  the  case  already  referred  to  (Gyn.  No. 
7193),  the  patient  had  what  at  first  sight  appeared  to  be  a  left  renal  colic.  The 
pain  began  in  the  renal  region,  and  radiated  down  the  course  of  the  ureter. 

Kouwer'*  attributed  a  complete  uterine  prolapsus  to  pressure  from  a  misplaced 

spleen  above  the  womb,  and  several  cases  of  intermittent  attacks  of  jaundice  have 

been  found  due  to  a  splenoptosis. 

'  Loc.  cit.  2  Osier.  W.:  "Prin.  and  Prac.  of  Med.,"  sixth  ed.,  1905. 

3  Llobet,  A.  F.:  "Splenectomie  totale."  Rev.  de  chir.,  1900,  xxi,  222. 

*Kouwer:  "Behandeling  der  waldelnde  milt  door  splenopexis,"  Nederl.  Tijdschrift  v.  Genees- 
kunde,  1895,  xxxi,  669. 


606  OPERATIONS    UPON   THE    SPLEEN. 

Acute  twisting  of  the  pedicle  presents  a  clinical  picture  like  that  familiar  in  the 
twisting  of  the  pedicle  of  an  ovarian  cyst;  great  pain,  abdominal  tenderness, 
rigidity,  fever,  and  leukocytosis  are  present.  The  shock  may,  in  some  cases,  be 
intense,  and  Richard  Douglas^  reports  an  instance  of  death  occurring  within  six 
hours  after  the  first  symptoms.  Unless  the  spleen  has  been  known  to  be  movable, 
the  diagnosis  before  celiotomy  in  such  a  case  may  be  impossible. 

The  diagnosis  that  the  particular  organ  in  distress  is  the  spleen  must  rest  on  a 
careful  exclusion  of  other  abdominal  organs  and  tumors,  especially  the  ovaries  and 
left  kidney,  also  the  detection  of  the  characteristic  notch  and  form  of  the  spleen. 
It  is  a  fact  to  be  noted  that  the  absence  of  splenic  dullness  is  often  misleading, 
though  its  presence  in  its  normal  site  is  of  greater  value.  A  movable  spleen  may 
occasion  great  distress.  Its  particular  dangers  are  rupture  of  the  stomach  or  duo- 
denum, intestinal  obstruction,  rupture  of  the  spleen,  and  twisting  of  its  pedicle. 
If  the  symptoms  are  slight,  treatment  may  be  limited  to  a  well-fitting  bandage.  I 
have  found,  however,  that  this  rarely  gives  relief  when  the  discomfort  is  exces- 
sive, and  in  such  cases  a  radical  operation  is  indicated. 

Splenectomy  is  a  safer  and  a  surer  expedient  than  those  procedures  which  are 
designed  to  produce  fixation  of  the  spleen  at  or  near  its  normal  habitat.  Splenopexy 
is  absolutely  contraindicated  when  the  spleen  is  diseased.  The  four  cases  on  which 
1  have  had  occasion  to  operate  all  had  a  history  of  malaria.  Stierlin^  found  malarial 
hypertrophy  in  thirteen  out  of  twenty-eight  cases  which  he  collected  out  of  the  lit- 
erature; and  thirty-two  splenectomies  for  wandering  spleen,  with  only  two  deaths, 
these  occurring  as  early  as  1874  and  1878.  ]\Iy  own  four  splenectomies,  I  found, 
did  well  after  operation,  and  all  have  remained  well  and  free  from  discomfort. 

Splenopexy  has  been  successfully  performed  by  several  methods,  though  I 
deprecate  the  use  of  sutures  passed  directly  through  the  tissues  of  the  organ,  as 
the  spleen  shows  a  great  tendency  to  break  loose,  and  severe  hemorrhage  occasionally 
takes  place.  Basil  HalP  describes  an  ingenious  procedure  in  the  case  of  a  spleen 
with  a  very  deep  notch.  He  used  the  notch  so  as  to  pocket  the  organ  in  a  peritoneal 
pouch,  leaving  only  half  of  it  projecting  into  the  general  peritoneal  cavity;  and 
my  colleague,  W.  S.  Halsted,  in  two  cases,  cited  by  Wm.  Osier,  successfully  fixed 
the  spleen  by  means  of  a  temporary  gauze  packing,  thus  producing  adhesions  which 
held  it  well  up;  but  in  view  of  the  simpler  convalescence  and  surer  results  of  splen- 
ectomy, such  operations  should,  as  a  rule,  not  be  employed. 


SIMPLE  HYPERTROPHY  OF  THE  SPLEEN. 
True  hypertrophy  of  the  spleen,  independent  of  all  known  causes  of  splenic 
enlargement,  and  not  associated  with  anemia,  is  occasionally  seen,     J.  C.  Warren* 

•  Douglas,  R.:  "Surgical  Diseases  of  the  Abdomen,"  1903,  p.  429. 

^Stierlin,  R.:  "Ueber  die  chirurgische  Behandlung  der  Wandermilz,"  Deut.  Ztschr.  f.  Chir., 
1897,  xlv,  382. 

^  Hall,  J.  Basil:  "Splenopexy  for  Wandering  Spleen,"  Ann.  of  Surg.,  1903,  xxxvii,  481. 

*  Warren,  J.  C:  "The  Surgery  of  the  Spleen,"  Ann.  of  Surg.,  1901,  xxxiii,  513. 


MALARIAL   HYPERTROPHY.  607 

states  that  it  is  common  among  the  Armenians  of  Boston,  and  has  no  special  cHnical 
significance.  The  inhabitants  of  southern  Italy  seem  also  to  be  liable  to  this  con- 
dition, which  may  persist  for  years  without  producing  any  deterioration  of  general 
health  and  give  rise  to  no  trouble.  When  it  causes  marked  discomfort,  which 
happens  occasionally,  the  spleen  should  be  removed.  D'Arcy  Powers^  reports  the 
successful  removal  of  a  large  spleen  of  this  kind  from  a  woman  forty-three  years  old. 

MALARIAL  HYPERTROPHY. 

The  ague-cake  spleen,  so  common  in  some  parts  of  the  United  States,  as  well 
as  in  all  other  regions  where  malaria  holds  sway,  sometimes  resists  all  drugs  and 
hygienic  treatment,  and  may  occasion  great  discomfort,  not  to  say  danger,  to  its 
unhappy  possessor.  Whether  there  are  good  grounds  or  not  for  the  theories  of 
Jonnesco"  and  others,  that  the  spleen  affords  both  a  harbor  and  breeding-place  for 
the  parasite  of  malaria,  the  fact  that  certain  intractable  malarial  infections,  associ- 
ated with  enlarged  spleen,  yield  to  splenectomy  after  resisting  everything  else,  is 
beyond  question. 

The  recognition  of  this  form  of  hypertrophy  rarely  causes  difficulty.  The  his- 
tory of  chronic  malaria,  if  the  actual  demonstration  of  the  plasmodium  in  the  blood 
fails,  makes  the  diagnosis  easy  and  positive. 

The  principal  indications  for  splenectomy,  which  is  the  only  surgical  procedure 
to  be  considered  in  this  connection,  are  pain  and  disturbed  function  in  other  organs 
dragged  or  pressed  upon  by  the  enlarged  spleen,  which  often  becomes  adherent  to 
its  surroundings.  We  must  not  forget  that  there  is  also  a  tendency  on  the  part  of 
such  a  spleen  to  rupture,  either  spontaneously  or  from  some  slight  trauma.  Osier 
notes  the  occurrence  of  this  serious  complication  after  a  simple  puncture  for  diag- 
nostic purposes. 

It  has  already  been  pointed  out  that  enlarged  spleen  and  failure  to  cope  with  an 
active  malarial  infection  by  medicinal  rneans  may  be  another  reason  for  surgery. 
But  it  is  to  be  constantly  kept  in  mind  that  most  hypertrophies  due  to  malaria  will 
yield  to  medicinal  treatment,  if  sedulously  employed,  and  that  surgery  is  always  a 
dernier  ressort.  Also  that  the  medicinal  treatment,  unless  the  symptoms  are  urgent, 
must  be  carried  on  for  months. 

Vulpius,^  in  1884,  collected  26  cases  with  1 1  deaths.  Nonnotti^  reports  9  personal 
cases  with  3  deaths.  The  presence  of  adhesions  is  shown  by  the  statistics  of 
Vanwerts.^  This  author  found  that  of  35  uncomplicated  splenectomies  for  malarial 
hypertrophy,  only  2  died  from  the  operation,  whereas  out  of  39  extensively  adherent 
cases,  no  less  than  28  were  lost.     Hartley''  reports  a  case  of  a  young  man  of  twenty- 

1  Powers,  D'Arcy:  "Successful  Removal  of  an  Enlarged  and  Displaced  Spleen,"  Brit.  Med. 
Jour.,  1900,  ii,  1428. 

2  Jonnesco,  T.:  "Ueber  Splenektomie,"  Arch.  f.  klin.  Chir.,  1897,  Iv,  330. 
^  Loc.  cit. 

*Nonnotti,  A.:  "Secondo  contributo  alio  studio  delle  indicazioni  della  splenectomia  nella 
splenomegalia  malarica,"  Centralb.  f.  Chir.,  1901,  xxviii,  703,  Abstract. 

^  Vanwerts,  J.:  ''De  la  splenectomie,"  These  de  Paris,  1897.  *  Loc.  cit. 


608  OPERATIONS    UPOX   THE    SPLEEN. 

four,  who  showed  a  marked  improvement  following  operation,  after  quinin  had 
proved  entirely  ineffectual. 

Extensive  adhesions,  then,  must  be  regarded  as  a  most  serious  complication,  if 
not  an  actual  contraindication  to  operation.  Among  other  contraindications  are 
advanced  age,  excessive  ascites,  and  a  high  degree  of  cachexia. 


BANTI'S  DISEASE. 

Several  closely  related,  if  not  identical,  splenic  affections  present  the  common 
associated  characteristics  of  anemia  and  splenomegaly.  Banti's  disease  is  the  best 
known  of  the  group,  to  which  Gaucher's  chronic  endothelioma  of  the  spleen,  and 
Taylor  and  Brill's  family  splenomegaly  belong. 

Tile  etiology  of  these  affections  is  obscure,  but  radical  operations  have  taught 
us  that  the  primary  seat  of  trouble  lies  in  the  spleen,  and  the  pathologic  changes 
found  in  the  liver  and  other  organs  must  be  due  to  a  toxin  manufactured  in  the 
diseased  organ. 

The  symptoms  in  the  early  stages  of  Banti's  disease,  in  addition  to  anemia 
and  enlargement  of  the  spleen,  consist  of  pigmentation  of  the  skin,  marked  digestive 
disturbances,  and  a  tendency  to  hemorrhage,  especially  gastric.  Osier  found  this 
symptom  in  seven  out  of  fifteen  cases,  and  has  especially  urged  its  diagnostic  im- 
portance. With  the  progress  of  the  disease,  the  weakness  and  the  anemia  increase 
'pari  passu,  cirrhosis  of  the  liver  develops  along  with  ascites  and  with  attacks  of 
intermittent  jaundice.  The  anemia  belongs  to  the  secondary  type,  that  is  to  say, 
the  color  index  of  the  individual  red  blood-cell  is  lower  than  normal.  The  actual 
number  of  red  blood-cells,  however,  also  decreases  from  the  beginning  of  the  dis- 
ease, and  in  the  last  stages  may  fall  as  low  as  1,500,000  per  cubic  millimeter. 

Gaucher's  disease^  is  characterized  by  a  transformation  of  the  splenic  pulp 
into  large  epithelioid  cells,  while  its  clinical  manifestations  are  very  similar  to  those 
of  Banti's  disease,  but  it  seems  to  progress  more  slowly. 

Frederick  Taylor,  Brill,  and  Fournier  have  described  a  very  slowly  progressive 
form  of  Banti's  disease,  characterized  by  the  fact  that  it  makes  its  onset  in  childhood, 
and  that  it  attacks  several  members  of  the  same  family. 

The  natural  course  of  these  diseases  is  progressive,  and  there  is  no  evidence  that 
any  medicinal  treatment  can  prevent  the  ultimate  death  of  those  attacked  by  them, 
though  the  results  of  early  surgical  interference  offer  more  hope.  Among  the  vari- 
ous reports  Bessel  Hagen  gives  sixteen  cases  of  splenectomy  for  Banti's  disease 
wdth  three  deaths  and  a  number  of  complete  and  permanent  recoveries.  Harris 
and  Herzog^  report  two  personal  cases  and  add  seventeen  others  from  the  literature, 
with  a  total  of  four  deaths.     An  interesting  case,  which  shows  that  surgery  may 

^Gaucher,  P.  C.  E.:  "  De  I'epithelioma  primitif  de  la  rate,  hypertrophie  idiopathique  de 
la  rate  sans  leucemie,"  These  de  Paris,  1882. 

^Harris,  M.  L.,  and  Herzog, M.:  "Splenectomy  in  Splenic  Anemia  or  Primary  Splenomegaly," 
Ann.  Surg.,  1901,  xxxiv,  111. 


CHRONIC    ENLARGEMENT   IN    INFANCY.  609 

benefit  even  in  the  last  stages,  is  given  by  Tancini/  In  addition  to  splenectomy, 
he  did  a  Talma  operation  (attachment  of  scarified  liver  and  omentum  to  the  ab- 
dominal wall)  in  the  case  of  a  woman  forty-six  years  of  age.  This  patient,  who  at 
the  time  of  operation  was  in  a  very  weak  condition  and  had  a  marked  ascites, 
seemed  perfectly  well  five  months  later.  Finkelstein^  reports  a  similar  case,  and 
Roger^  reports  two  others,  which  were  successful.  J.  Collins  Warren,*  of  Boston, 
has  collected  twenty-five  splenectomies  for  Gaucher's  disease,  with  twenty  recoveries. 
Whenever  a  splenomegaly  with  a  secondary  anemia  of  unknown  origin  persists 
for  some  time,  even  without  the  skin  pigmentation  and  later  manifestations  of 
Banti's  disease,  the  indication  is  positive  to  perform  splenectomy.  Notwithstanding 
the  advisability  of  operation  as  early  as  possible  in  the  course  of  the  disease,  it 
may  be  done  with  every  hope  of  success  even  in  its  later  stages. 

CHRONIC  ENLARGEMENT  IN  INFANCY. 

It  is  not  uncommon  to  meet  with  cases  of  enlarged  spleen  associated  with  anemia 
in  children  under  two  and  up  to  six  years  of  age.  The  two  common  causes  of  this 
enlargement  are  syphilis  and  rickets,  but  cases  sometimes  occur  independent  of  these 
affections.  This  condition  does  not  correspond  with  Banti's  disease  in  adults 
and  most  of  the  patients  recover  under  proper  medicinal  treatment.  In  studying 
this  group  of  cases,  a  knowledge  of  the  normal  blood  conditions  in  infancy  and  child- 
hood is  absolutely  necessary. 

These  diseases  are  not  surgical. 

An  excellent  resume  will  be  found  in  R.  Hutchinson's  Gulstonian  Lecture.^ 


TRAUMA. 

Injuries  to  the  spleen  by  contusions,  penetrating  objects,  and  gunshot  wounds 
are  not  uncommon,  although  the  damage. is  not  always  limited  to  the  spleen;  the 
associated  injuries  of  other  organs  being  usually  so  extensive  as  to  entirely  mask  the 
splenic  injury. 

Subcutaneous  or  internal  rupture  of  the  organ,  that  is  to  say,  rupture  in  which  the 
abdominal  parietes  show  no  solution  of  continuity,  is  the  commonest  and  most 
dangerous  form  of  trauma.  Such  an  injury  may  vary  all  the  way  from  a  slight  tear 
of  the  capsule  to  a  complete  morcellation  of  the  spleen. 

Mixter^  reports  a  splenectomy  where,  on  opening  the  abdomen,  one  end  of  the 

^Tancini,  I.:  " Die  Splenektomie  und  die  Talma'sche  Operation  bei  der  Bantischen  Krank- 
heit,"  Arch.  f.  klin.  Chir.,  1902,  Ixvii,  874. 

2  Finkelstein,  B.  K.:  "Splenektomie  und  Talma'sche  Operation  bei  Malariaascites,"  Centralbl. 
f.  Chir.,  1903,  xxx,  1423. 

^ Roger,  J.:  "La  splenectomie  dans  la  maladie  de  Banti,"  Presse  med.,  1903,  ii,  535. 

^Loc.  cit. 

^Hutchinson,  R.:  "On  Some  Disorders  of  the  Blood  and  Blood-forming  Organs  in  Early- 
Life,"  Lancet,  1904,  i,  1253. 

^Mixter,  S.  J.:  "Cases  of  Laceration  of  the  Spleen  and  of  the  Kidney  followed  by  Recovery- 
after  the  Removal  of  the  Injured  Organ,"  Ann.  of  Surg.,  1901,  xxxiii,  713. 
VOL.  II — 39 


610 


OPERATIONS    UPON   THE    SPLEEN. 


spleen  was  found  torn  entirely  loose  and  lying  free  in  the  abdominal  cavity,  while 
the  still  attached  portion  was  bleeding  furiously. 

Rupture  of  the  spleen  frequently  leads  to  severe  pain  in  the  left  epigastric  region, 
but  the  condition  is  so  frequently  masked  by  collapse  and  exsanguination  that  a 
positive  diagnosis  before  opening  the  abdomen  is,  as  a  rule,  next  to  impossible.  A 
history  of  a  previously  enlarged  spleen  is  most  suggestive,  as  it  is  the  hypertrophied 
organs  which  rupture  most  readily.  A  large  malarial  spleen  occasionally  ruptures 
spontaneously. 

Edler,^  in  an  analysis  of  seventy-eight  cases  of  splenic  injury,  found  that  in 
fifty-seven  the  spleen  was  the  organ  principally  or  solely  involved,  and  out  of  these 

fifty-seven    spleens,    twenty-four 
were  found  markedly  diseased. 

The  indication  for  prompt 
surgical  treatment  in  splenic 
rupture  is  most  urgent,  as  a 
spontaneous  recovery  is  practic- 
ally unknown,  and  the  safest 
and  best  surgical  procedure,  be- 
yond all  doubt,  is  a  splenectomy. 
Suturing  the  ruptured  spleen  has 
been  successfully  done  in  a  num- 
ber of  instances,  but  this  con- 
sumes more  time  and  is  attended 
by  greater  risk  than  splenectomy, 
and  it  should  be  considered  only 
in  those  cases  where  the  tear  is 
small  in  extent  and  the  spleen 
otherwise  normal. 

Quick  service  should  be  the 
surgical  motto,  in  a  condition 
which  is  fairly  comparable  to  a 
ruptured  extrauterine  pregnancy. 
When  the  value  of  surgery  was 
still  questioned  and  late  operations  the  rule,  the  mortality  was  almost  100  per  cent., 
as  Hartley  pointed  out  as  early  as  1894.  The  commonest  cause  of  death  is  hemor- 
rhage, and  next  to  that  comes  peritonitis.  Vincent^  found  that  out  of  one  hundred 
deaths,  seventy-five  were  due  to  hemorrhage. 

M.  Jordan^  reports  three  personal  cases  and  adds  twenty-five  collected  by  Adel- 
mann*  in  which  the  operation  cured  the  patient. 

'  Edler,  L.:  "Die  traumatischen  Verletzungen  der  parenchymatosen  Unterleibsorgane," 
Arch.  f.  klin.  Chir.,  1887,  xxxiv,  173. 

^Vincent, E.:  "Reflexions  sur  le  pronostic  et  le  traitement  des  ruptures  de  la  rate,"  Rev.  de 
chir.,  1893,  xiii,  449. 

^  Log.  cit. 

^Adelmann,  G.:  "Die  Wandlungen  der  Splenektomie  seit  dreissig  Jahren,"  Arch.  f.  klin. 
Chir.,  1887,  xxxvi,  442. 


Fig.  781. — Spleen  of  a  Seventeen-year-old  Negro  Girl, 
Ruptured  by  the  Kick  of  a  Man  in  Her  Left  Side. 
(Removed  by  Dr.  E.  A.  Ballock,  "Annala  of  Surgery," 
1902.) 


CYSTS    OF   THE    SPLEEN.  611 

Gunshot  injuries  to  the  spleen  should  be  suspected  from  a  study  of  the  location 
of  the  wounds  in  the  abdominal  walls,  but  an  accurate  diagnosis  comes  only  through 
an  exploratory  laparotomy,  and  the  same  principles  govern  here  as  in  other  splenic 
injuries;  if  there  is  considerable  hemorrhage,  the  spleen  should  be  removed. 

A  curious  injury  which  occurs  occasionally  and  deserves  special  mention  is  a 
hernia  of  the  spleen  through  a  wound  in  the  abdominal  wall;  it  has  been  known  to 
escape  entirely  outside  the  cavity  and  for  months  remain  on  the  surface,  a  fungous 
bleeding  mass.  If  the  case  is  seen  soon  after  the  injury,  and  if  the  organ  is  normal, 
it  should  be  replaced  in  the  abdomen,  provided  this  can  be  easily  done;  under  all 
other  circumstances,  splenectomy  is  indicated. 


CYSTS  OF  THE  SPLEEN. 

The  cause  and  course  of  the  development  of  splenic  cysts  is  an  obscure  subject 
demanding  further  elucidation.  The  generally  accepted  view  is  that  they  begin 
with  an  extravasation  of  blood  into  the  splenic  pulp,  ending  by  forming  a  so-called 
blood  cyst;  it  is  then  conjectured  that  in  a  certain  proportion  of  these  cases  the  blood 
becomes  absorbed  and  replaced  by  a  serous  fluid,  thus  accounting  for  the  serous 
cyst. 

Jordan,  when  reporting  a  personal  case,  found  eleven  others  in  the  literature; 
he  observed  that  the  majority  occurred  in  the  third  decade  of  life,  and  that  out  of 
the  twelve  cases,  ten  were  women. 

In  June,  1895,  a  woman,  thirty-eight  years  old,  came  to  the  Gynecological  Clinic 
of  the  Johns  Hopkins  Hospital  complaining  of  an  abdominal  tumor.  Her  family 
history  was  excellent  and  she  stated  that  until  the  present  illness  her  health  had  been 
of  the  best.  In  February  of  that  year  her  attention  was  called  to  a  small  body  in 
her  left  side  by  a  slight  pain  at  that  point.  The  body  continued  to  grow  steadily 
until  it  reached  the  size  of  a  child's  head.  I  made  a  correct  diagnosis  before  opera- 
tion, and  finding  the  spleen  free,  I  first  removed  the  cyst  and  then  sutured  the  spleen. 
Convalescence  was  rapid  and  the  patient  has  remained  in  the  best  of  health  up  to 
this  time  (1907). 

Cysts  of  the  spleen  rarely  manifest  themselves  until  they  have  reached  con- 
siderable size,  or  occasioned  sufficient  discomfort  to  call  the  patient's  attention  to 
their  presence. 

Opening  and  evacuation  with  drainage  is  sufficient  to  insure  recovery,  but  when 
the  walls  are  thick  and  calcareous  they  should  be  removed  by  peeling  out  or  by 
curettage.  Bardenheuer  has  suggested  a  partial  resection,  when  the  cyst  is  favorably 
located. 

When  the  adhesions  are  slight  and  there  are  a  number  of  small  cysts,  splenec- 
tomy is  indicated;  Bessel  Hagen  collected  seven  cases  successfully  treated  in  this 
manner. 


612  OPERATIONS    UPON   THE   SPLEEN. 

ECHINOCOCCUS  CYST. 

Cases  of  this  disease  are  rare  in  America,  where  but  few  echinococcus  infections 
of  any  kind  occur.  The  disease  is  contracted  from  dogs,  and  the  actual  infecting 
agent  is  the  larva  of  the  Tenia  echinococcus.  The  splenic  involvement  is  practically 
always  associated  with  cysts  in  other  organs.  Trinkler^  collected  seventy  cases  of 
echinococcus  disease  of  the  spleen,  and  he  estimates  that  in  3.2  per  cent,  of  all 
echinococcus  infections  this  organ  is  involved. 

The  symptoms  vary  greatly,  depending  on  the  size  and  situation  of  the  cysts. 
When  these  are  small  and  deeply  located,  there  may  be  no  disturbances  whatever; 
on  the  other  hand,  when  they  are  large,  and  accompanied  by  pressure  and  by  adhe- 
sions, great  pain  and  discomfort  are  common. 

In  a  differential  diagnosis,  cystic  tumors  of  the  other  abdominal  organs,  and  espe- 
cially of  the  ovaries  and  of  the  kidneys,  must  be  excluded.  The  demonstration  of 
echinococcus  cysts  in  other  organs,  associated  with  a  history  of  exposure  to  the 
disease,  aid  in  separating  these  tumors  from  other  kinds  of  cysts  of  the  spleen. 
Trinkler  observed  that  in  twenty-four  out  of  fifty-one  cases,  fluctuation  was  noted, 
and  that  in  eight,  the  pecuhar  crepitation  and  bruit  characteristic  of  this  kind 
of  cyst  was  obtained.  In  some  instances  the  diagnosis  can  only  be  made  by  a 
microscopic  examination,  with  the  demonstration  of  the  characteristic  booklets. 

The  presence  of  such  a  cyst  is  a  positive  indication  for  operation,  and  splenec- 
tomy is  the  operation  of  choice. 

In  certain  cases,  when  extensive  and  vascular  adhesions  are  present,  more  con- 
servative procedures  have  been  employed.  The  cyst  may  then  be  emptied,  and  as 
far  as  possible  its  lining  destroyed;  great  care  should  be  taken  to  prevent  the  con- 
tents from  coming  into  contact  with  the  peritoneum  or  the  abdominal  incision. 

J.  Petit,^  after  draining  such  a  cyst,  saw  cysts  develop  in  the  abdominal  wall. 
On  account  of  their  danger,  cysts  of  the  spleen  should  be  aspirated  for  diagnosis 
only  after  the  abdomen  is  open  and  the  spleen  so  isolated  that  infection  of  the 
peritoneum  by  escape  of  fluid  is  impossible.  Jordan  reports  one  personal  case  and 
adds  seventeen  from  the  literature,  where  splenectomy  was  done  for  echinococci; 
of  these  seventeen  cases,  but  one  was  multilocular;  thirteen  were  in  women. 

The  evidence  of  extensive  echinococcus  disease  of  other  organs  is  a  contra- 
indication to  operation. 

ABSCESS  OF  THE  SPLEEN. 
The  formation  of  abscesses  in  the  spleen  in  cases  of  pyemia  is  a  common  occur- 
rence, but  such  abscesses  are  usually  small,  and  not  recognizable  during  the  hfe 
of  the  patient.     Primary  abscess  in  the  spleen  is  rare.     Douglas^  gives  a  resume  of 
seven  cases  reported  by  Bessel  Hagen^  and  adds  three  others. 

'  Trinkler, N.:  "Kyste  hydatique  solitaire  de  la  rate,"  Centralbl.  f.  Chir.,  1894,  xxi,  860  (ref.). 
2 Petit,  J.:  "Greffes  d'un  kyste  hydatique  de  la  rate,"  Centralbl.  f.  Chir.,  1901,  xxviii,  120. 
^Loc.  cit.  *Loc.  cit. 


TUBERCULOSIS    OF   THE    SPLEEN.  613 

The  origin  of  splenic  abscess  is  frequently  most  obscure;  a  few  have  followed 
blows,  and  the  case  referred  to  under  movable  kidney  followed  a  twisting  of  the 
splenic  pedicle. 

The  chnical  course  is  marked  by  septic  fever,  leukocytosis,  loss  of  weight,  and 
marked  digestive  disturbances,  particularly  diarrhea.  Localized  tenderness  and 
pain  are  usually  present  and  not  infrequently  an  edema  of  the  overlying  abdominal 
wall  is  observed. 

Abscesses  of  considerable  size  do  not  heal  spontaneously;  rupture  into  the 
stomach  or  into  the  intestines  is  commoner  than  through  the  abdominal  wall.  If 
adhesions  are  absent,  or  are  such  as  can  be  readily  dealt  with,  splenectomy  is  the 
operation  of  choice.  Bessel  Hagen  reports  seven  cases  successfully  treated  by  this 
means. 

When  the  spleen  is  adherent,  the  most  effectual  as  well  as  the  safest  method  of 
procedure  is  along  the  line  employed  by  Lauenstein,  in  a  case  where,  after  exposing 
the  spleen  and  sewing  the  capsule  to  the  abdominal  wall,  he  incised  it  with  a  Pa- 
quelin  cautery,  and  then  effectually  established  drainage.  Such  an  operation  is  far 
from  ideal,  but  it  is  the  best  under  the  circumstances. 


TUBERCULOSIS  OF  THE  SPLEEN. 

Although  it  is  not  such  a  rare  thing  to  demonsti'ate  the  spleen  as  the  principal 
focus  of  a  tubercular  infection  at  the  post-mortem  table,  primary  tuberculosis  of 
the  spleen  is  most  uncommon,  and  tuberculosis  limited  to  the  spleen  belongs  among 
the  rarest  conditions  found  at  autopsies.  In  the  general  dissemination  of  tubercles 
accompanying  an  acute  miliary  infection,  the  spleen  is  almost  invariably  involved. 

Although,  when  subjected  to  the  rigid  autopsy  test,  but  few  primary  splenic 
tuberculoses  seem  to  occur,  they  are  more  common  clinically,  and  among  other  reli- 
able writers  on  the  subject,  Joseph  Bayer^  has  contributed  greatly  to  our  knowl- 
edge of  this  condition,  through  his  collection  and  analysis  of  nine  operative  and 
nineteen  autopsy  cases. 

In  the  early  stages  of  the  disease  the  patient  may  feel  perfectly  well.  Pain  in 
the  splenic  region  is  frequently  present,  and  in  the  case  of  large  abscesses  may  be 
intense.  The  spleen  may  not  be  materially  enlarged,  although  it  occasionally  attains 
great  size.  When  the  disease  is  extensive  and  active,  the  fever,  sweats,  and  chills 
characteristic  of  tuberculosis  in  other  parts,  may  set  in.  In  addition  to  anemia, 
hyperglobulia  has  been  noted;  there  is  no  leukocytosis. 

In  making  a  diagnosis  in  a  doubtful  case,  tuberculin  might  be  given  with  advan- 
tage.    The  course  of  the  disease  is  usually  «low  and  extends  over  several  years. 

The  operative  indication  is  to  do  splenectomy  as  soon  as  the  condition  is 
diagnosed.  In  cases  where  large  abscesses  are  present  and  the  organ  densely 
adherent,  this  procedure  may  have  to  be  preceded  by  splenotomy  with  drainage. 

1  Bayer,  J.:  "Ueber  die  primare  Tuberkulose  der  Milz.,"  Mitth.  a.  d.  Grenzgeb.  d.  Med.  u. 
Chir.,  1904,  xiii,  523. 


614 


OPERATIONS    UPON   THE    SPLEEN. 


The  general  condition  of  the  patient  and  the  local  condition  of  the  spleen  in  the 
individual  case  will  influence  the  operator  as  to  the  particular  method  to  be  employed. 

Jordan  quotes  the  successful  operations  of  Harriot  and  Bland-Sutton,  while 
Joseph  Bayer  found  seven  recoveries  and  two  deaths  in  nine  cases  of  splenectomy 
for  splenic  tuberculosis. 

Extensive  and  active  tuberculosis  in  other  organs  is  a  contraindication  to  any 
surgery  other  than  opening  an  abscess  which  immediately  threatens  the  life  of  the 
patient. 

SARCOMA. 
Although  almost  all  malignant  tumors  of  the  spleen  are  of  sarcomatous  nature, 

yet  sarcoma  of  the  spleen  is 
rare.  Up  to  1894,  splenectomy 
had  been  performed  five  times 
for  this  condition.  Billroth's 
case  (1884)  died  from  recur- 
rence six  months  after  the 
operation;  Fritsch's  cases 
(1888)  remained  permanently 
well;  Kocher's  (1888)  had  a 
recurrence  in  the  glands; 
Flothmann's  (1889)  died  soon 
after  operation,  as  a  result  of 
hemorrhage ;  Wagner's  ^  was 
cured. 

The  symptoms  are  usually 
not  pronounced  during  the 
early  stages  of  the  disease.  In 
AYagner's  case,  above  referred 
to,  occurring  in  a  woman 
twenty-three  years  of  age, 
there  were  no  subjective  symp- 
toms, but  the  patient  noticed 
the  mass  in  her  abdomen. 
Gastro  -  intestinal  symptoms 
are  usually  present,  and  in  the  later  stages  of  the  disease  a  marked  ascites  fre- 
quently develops. 

The  outlook  of  an  untreated  patient  with  sarcoma  of  the  spleen  is  of  course 
hopeless;  the  disease  develops  rapidly  and  invariably  ends  fatally.  Splenectomy 
should  be  undertaken  as  soon  as  the  condition  is  suspected.  If  the  disease  is  in 
an  early  stage,  the  result  ought  to  be  a  good  one.     When  laparotomy  demonstrates 

^Wagner,  W.:  "Exstirpation  der  sarkomatosen  Wandermilz,"  Centralbl.  f.  Chir.,  1894,  xxi, 
Beilag  55.  Dr.  Wagner  has  died  since  his  report,  and  his  patient,  who  lived  several  years,  has 
been  lost  sight  of. 


Fig.  782. — Sarcoma  of  Spleen. 
(From  W.  Jepson  and  F.  Albert,  "Annals  of  Surgery,"  1904.) 


SYPHILIS. — AMYLOID    SPLEEN. — ANGIOMA    CAVERNOSUM. — LEUKEMIA.  615 

that  the  organ  is  densely  adherent  to  the  pancreas,  the  stomach,  and  the  intestines, 
a  permanent  cure  cannot  be  expected;  and  the  primary  mortahty  here  is  very  great. 
It  is  easy  to  induce  an  uncontrollable  hemorrhage,  as  in  the  unhappy  experience 
of  a  great  surgeon  of  my  acquaintance. 

SYPHILIS. 

Enlargement  of  the  spleen  is  common  in  congenital  syphilis,  and  in  infected 
syphilitic  lesions  amyloid  change  in  the  organ  is  frequent.  Great  enlargement  may 
result  from  the  presence  of  gummata;  Hartley  reports  the  successful  removal  of 
such  a  spleen.  The  local  symptoms  will  depend  on  the  size  and  location  of  the 
gummata;  usually,  marked  evidence  of  tertiary  syphilis  will  be  found  in  other 
organs. 

The  treatment  is  medicinal,  not  surgical. 

AMYLOID  SPLEEN. 

Moderate  amyloid  change  in  the  spleen  is  not  infrequently  encountered  at  the 
autopsy  table,  and  the  tremendously  enlarged  sago-spleen  is  well  known.  Such 
a  spleen  is  associated  with  amyloid  changes  in  other  organs,  and  the  causes  of 
amyloid  disease,  chronic  suppuration,  or  syphilis  are  always  present. 

Vulpius^  in  1894  collected  three  splenectomies  performed  for  this  condition. 
They  all  ended  fatally.  The  condition  is  mentioned  in  order  to  note  that  it  forms 
a  contraindication  to  operation. 

ANGIOMA  CAVERNOSUM. 

Hoge^  reports  the  pathologic  findings  in  a  spleen  removed  for  this  condition  by 
Hunter  McGuire.  The  patient  gave  a  history  of  alternating  attacks  of  constipa- 
tion and  diarrhea,  with  marked  loss  of  "weight  and  strength.  On  examination,  the 
spleen  was  found  to  extend  all  the  way  from  the  costal  margin  to  the  pelvis.  Stuart 
McGuire  writes  that  this  patient  has  been  lost  sight  of  since  leaving  the  hospital. 

Homans^  reports  a  case  with  bloody  ascites.  His  description  sounds  more  like 
that  of  a  sarcoma  than  an  angioma  cavernosum. 


LEUKEMIA. 

Leukemia,  especially  the  spleno-myelogenous  form,  may  lead  to  enormous  in- 
crease in  the  size  of  the  spleen,  and  it  is  not  infrequent  for  the  consequent  enlarge- 
ment of  the  abdomen  to  be  the  first  and,  it  may  be,  only  complaint  of  the  patient. 
A  few  years  ago,  in  one  of  the  gynecologic  wards  of  the  Johns  Hopkins  Hospital,  I 

^  Loc.  cit. 

^Hoge,  M.  D.:  "Angioma  Cavernosum  of  the  Spleen,"  Med.  Rec,  1895,  xlviii,  418. 
'Homans,  John:  "Report  of  a  Case  of  Cavernous  Angioma  of  the  Spleen,"  Ann.  of  Surg., 
1897,  XXV,  732. 


616  OPERATIONS   UPON   THE   SPLEEN. 

had  two  such  cases  sent  in  at  one  time  with  the  diagnosis  of  renal  tumor.  The 
routine  examination  of  the  blood  disclosed  the  unsuspected  leukemia. 

The  spleen  is  usually  somewhat  tender,  and  marked  digestive  disturbances  are 
almost  constantly  present.  Not  infrequently  the  temperature  runs  an  irregularly 
elevated  course. 

The  characteristic  changes,  however,  occur  in  the  blood,  and  it  is  upon  the  blood 
examination  that  the  diagnosis  must  rest.  The  proportion  of  white  blood-cells  to 
red  blood-cells  is  greatly  increased.  This  proportion  usually  reaches  1  to  10,  and 
cases  are  on  record  where  the  white  blood-cells  actually  predominated.  In  the 
spleno-myelogenous  form,  more  than  30  per  cent,  of  the  white  blood-cells  are  made 
up  of  a  cell  (myelocyte)  normally  present  in  the  bone-marrow,  but  not  in  the  blood. 
It  is  a  polymorphonuclear  cell,  contains  neutrophilic  granules,  and  is  about  three 
times  the  size  of  the  ordinary  polymorphonuclear  leukocyte.  Large  cells  with 
basophilic  granules  are  common.  Nucleated  red  blood-cells  are  present  in  consid- 
erable numbers. 

In  lymphatic  leukemia  the  relative  increase  in  the  white  cells  is  not  so  great.  A 
proportion  of  1  to  10  is  very  rare.  There  are  no  myelocytes  and  the  increase  is  due 
solely  to  lymphocytes,  which  are  small,  round,  mononuclear  cells.  These  cells 
may  constitute  99  per  cent,  of  the  white  cells. 

Pseudo-leukemia,  or  Hodgkin's  disease,  may  present  all  the  symptoms  of  lymph- 
atic leukemia,  enlarged  spleen,  enlarged  lymph-glands,  and  associated  anemia, 
but  the  blood  does  not  show  an  increase  or  change  in  the  white  formed  elements. 

I  wish  to  state  emphatically  that  none  of  these  conditions  is  permanently  bene- 
fited by  splenectomy  and  that  the  operative  mortahty  is  extremely  high.  Bessel 
Hagen'  collected  out  of  the  Hterature  forty-two  such  cases;  thirty-eight  of  which  died 
immediately  from  the  operation,  three  survived  a  short  time,  and  one  lived  for  a 
considerable  period.  J.  Collins  Warren,^  in  his  comprehensive  paper,  adds  a  case 
of  Maurice  Richardson,'  of  Boston,  to  those  collected  by  Bessel  Hagen.  This  pa- 
tient survived  the  operation  for  some  time,  but  was  not  cured,  and  Richardson  later 
reported  her  death.  M.  Jordan,  1903,  came  to  the  conclusion,  after  carefully  study- 
ing the  question,  that  not  a  single  recovery  from  leukemia  had  followed  the  opera- 
tion. 

In  two  splenectomies  for  Hodgkin's  disease  on  record,  Burckhardt's  Hved 
fourteen  and  one-half  weeks,  and  one  case,  operated  upon  by  Kummel,  survived 
eight  weeks. 

These  conditions  should  always  be  kept  in  mind  when  considering  the  nature 
of  a  splenic  tumor  and,  in  view  of  the  wretched  results  of  operation,  must  be  excluded 
before  removal  of  the  spleen  is  undertaken. 

^Loc.  cit.  ^Loc.  cit. 

5 Richardson,  M.:  "A  Case  of  Splenectomy  for  Myelogenous  Leukfemia,"  Tr.  Am.  Surg.  Assoc, 
1904,  xxii,  386. 


CHAPTER  XXXVIII. 

TUBERCULOSIS  OF  THE  PERITONEUM. 
By  George  Ben  Johnston,  M.D. 

HISTORICAL. 

In  this  country  attention  was  first  called  to  the  operative  treatment  of  tubercu- 
losis of  the  peritoneum  in  1887  by  Ely  Van  de  Warker/  of  Syracuse,  in  a  monograph 
entitled  "Laparotomy  as  a  Cure  for  Tuberculosis  of  the  Peritoneum."  His  con- 
clusion was  that  "it  is  safe  to  assume  that  opening  of  the  abdomen  in  instances  of 
tubercular  degeneration  of  its  lining  membrane  is  comparatively  free  from  danger, 
and,  in  view  of  its  possible  benefit,  amply  justified." 

The  knowledge  of  peritoneal  tuberculosis,  according  to  Borchgrevink,"  dates 
back  to  the  year  1825,  in  the  time  of  Louis,  when  only  sporadic  cases  of  the  disease 
were  known,  so  that  the  diagnosis  was  seldom  made.  During  the  period  of  1825 
to  1884,  tuberculosis  of  the  peritoneum  as  a  clinical  entity  began  to  attract  attention. 
It  was  considered  to  be  invariably  fatal,  however,  and  comparable  in  its  ravages  to 
malignant  disease. 

In  1862,  Sir  Spencer  Wells  performed  a  laparotomy  on  a  young  woman,  aged 
twenty-two,  believed  to  be  the  subject  of  an  ovarian  tumor.  Upon  opening  the 
abdomen  he  found  a  typical  picture  of  tuberculous  peritonitis.  He  removed  the 
effusion  and  closed  the  incision.  The  patient  recovered,  was  married  several  years 
later,  and  twenty-five  years  after  the  operation  maintained  her  good  health.  In 
1878,  Dohrn  operated  upon  a  child  of  four  years  for  a  similar  reason  with  like  result. 
In  the  same  year  Naumann  found  four  cases  at  operation,  two  of  which  recovered. 
Analogous  cases  were  reported  by  Hegar,  Feldmann,  Mosetig-Moorhof,  Lindfors, 
Petri,  Graefe,  Kappeler,  and  others,  many  of  which  ended  in  recovery. 

To  Konig  belongs  the  credit  of  having  first  advised  surgical  intervention  in 
instances  of  tuberculosis  of  the  peritoneum.  In  1884,  when  a  surgeon  at  Gottingen, 
he  reported^  four  cases  of  this  disease  submitted  to  operation,  three  of  which  were 
cured.     In  this  communication  he  proposed  laparotomy  as  the  treatment  in  all 

^Van  de  Warker,  Ely:  "Laparotomy  as  a  Cure  for  Tuberculosis  of  the  Peritoneum,"  Am. 
Jour.  Obst.,  N.  Y.,  1887,  xx,  932-941 . 

^Borchgrevink,  O.:  "Klinische  und  experimentelle  Beitriige  zur  Lehre  von  der  Bauchfell- 
tuberkulose,"  Biblioth.  Med..  Stuttg.,  1901,  Abt.  E,  Hft.  4,  1-233. 

^  Konig,  F.:  "Ueber  diffuse  peritoneale  Tuberkulose  und  die  durch  solche  hervorgerufenen 
Scheingeschwiilste  im  Bauch,  nebst  Bemerkungen  zur  Prognose  und  Behandlung  dieser  Krankheit," 
Centralbl.  f.  Chir.,  Leipz.,  1884,  xi,  81-85. 

617 


618  TUBERCULOSIS    OF   THE    PERITONEUM. 

cases  of  tuberculosis  of  the  peritoneum  as  soon  as  the  diagnosis  is  made.  Three 
years  later  Kiimmel  reported  40  cases  with  operation,  and  in  1890  Konig^  collected 
and  presented  at  the  Congress  of  Surgeons  in  Berlin  131  instances,  including  his 
own  cases,  that  had  been  treated  by  laparotomy.  In  this  second  series  of  cases 
apparent  cure  was  obtained  in  84  instances,  or  65  per  cent.,  although  in  only  30  of 
the  cases  had  the  operation  been  more  than  two  years  prior  to  the  date  of  the 
report. 

Others  soon  followed,  and  in  1892  Lindner  reported  205  cases;  Aldibert,  308 
cases;  Roersch,  in  1893,  collected  358  cases;  and  Adossidies,  in  the  same  year,  com- 
piled 405  cases.  In  1896,  Margarucci  collected  253  cases  operated  upon  by  members 
of  the  Italian  Surgical  Society,  showing  216  instances,  or  85.4  per  cent,  of  cures. 
Since  that  time  many  sets  of  statistics  dealing  with  the  operative  treatment  of  tuber- 
culous peritonitis  have  appeared,  and  the  careful  study  has  led  to  a  general  employ- 
ment of  laparotomy  in  suitable  cases. 

At  the  same  time  that  the  surgical  treatment  of  tuberculosis  of  the  peritoneum 
was  attracting  so  much  attention  various  other  features  of  the  affection  received 
a  considerable  amount  of  study.  The  different  clinical  forms  of  the  disease  were 
separated,  the  etiology  and  pathologic  anatomy  of  this  form  of  tuberculosis  were 
carefully  investigated,  and  the  possibility  of  effecting  a  permanent  cure  by  other 
than  surgical  means  was  insisted  upon  by  several  writers.  Osier,  in  this  country, 
gave  the  subject  special  attention,  and  he  was  the  first  to  make  a  histologic  study 
of  the  process  of  healing  after  abdominal  incision.  In  an  extensive  monograph^  in 
1890,  he  took  up  the  consideration  of  the  disease  in  much  detail  and  drew  the  fol- 
lowing general  conclusions : 

First,  that  tuberculous  peritonitis  is  often  a  latent  affection,  localized  in  the  peri- 
toneum, which  may  even  run  its  course  without  inducing  special  symptoms. 

Second,  that,  as  in  other  local  tuberculous  processes,  there  is  in  this  a  natural 
tendency  to  healing,  which  takes  place  more  frequently  than  has  hitherto  been 
supposed. 

Third,  that  statistical  evidence  shows  laparotomy  to  be  in  many  cases  a  palliative, 
and  in  some  instances  a  curative,  measure. 

The  medical  treatment  of  tuberculosis  of  the  peritoneum  has  been  strongly 
advocated  by  many  writers  on  the  subject.  Borchgrevink,  especially,  has  insisted 
on  the  internal  treatment  of  this  affection,  and  has  supported  his  contention  by  the 
report^  of  finding  a  spontaneous  cure  in  82.3  per  cent,  of  cases  so  treated,  as  against 
the  average  primary  result  of  cure  by  laparotomy,  which  he  states  to  be  from  65  to 
70  per  cent.     Other  papers  either  advocating  or  considering  the  medical  treatment 

^Konig,  F.:  "Die  peritoneale  Tuberkulose  und  ihre  Heilung  durch  den  Bauchschnitt," 
Centralbl.  f.  Chir.,  Leipz.,  1890,  xvii,  657-660. 

^ Osier,  William:  "Tuberculous  Peritonitis.  General  Considerations.  Tubercular  Abdom- 
inal Tumors.     Curability,"  Johns  Hopkins  Hosp.  Rep.,  Bait.,  1890,  ii,  67-113. 

2  Borchgrevink,  O.:  "Zur  Kritik  der  Laparotomie  bei  der  serosen  Bauchfelltuberkulose. 
Ein  klinischer  und  experimenteller  Beitrag  zur  Lehre  von  der  Bauchfelltuberkulose,"  Mitt.  a.  d. 
Grenzgeb.  d.  Med.  u.  Chir.,  Jena,  1900,  vi,  434-450. 


ETIOLOGY.  619 

of  tuberculosis  of  the  peritoneum  are  those  of  Teleky/  Shattuck/  Osier/  Schroeder/ 
Sutherland,^  Hugentobler,''  and  others. 


ETIOLOGY. 

Incidence. — It  is  now  well  recognized  that  tuberculous  peritonitis  is  not  a  rare 
affection.  The  most  extensive  statistics  bearing  on  this  feature  of  the  disease  are 
those  compiled  by  Engelmann.^  He  found  that  of  2837  autopsies  in  a  period  of  four 
years  at  the  Munich  Pathological  Institute,  1.6  per  cent,  of  all  cases  were  tuberculous 
peritonitis;  that  of  8421  cases  from  the  Berlin  Pathological  Institute  which  came 
to  autopsy  during  ten  years,  2.5  per  cent,  were  from  this  disease.  In  Erlangen  the 
statistics  covering  twenty-three  years  of  autopsy  records  gave  1.4  per  cent.,  and  in 
Kiel  5425  autopsies  in  fifteen  years  gave  1  per  cent.  In  these  reports  are  cited  only 
those  cases  which  resulted  fatally  from  tuberculous  peritonitis;  other  forms  of  peri- 
tonitis, as  are  found  in  miliary  tuberculosis  or  in  grave  tuberculous  disease  of  other 
organs,  are  not  here  included.  At  the  Pathological  Institute  of  the  University  of 
Prague  the  statistics  of  tuberculous  peritonitis  covering  3500  autopsies  include  also 
the  incidental  finding  of  tuberculosis  of  the  peritoneum,  and  give  a  percentage  of 
4.7  for  this  condition. 

Bottomley,^  quoting  from  Nothnagel,  states  that  from  reported  observations  on 
tuberculous  patients  the  peritoneum  was  involved  in  from  1.25  to  16.16  per  cent.,  a 
wide  variation.  In  his  previously  collected  statistics^  he  found  that  in  1170  autopsies 
at  the  Boston  City  Hospital  from  January,  1895,  to  January,  1900,  tuberculosis 
was  present  in  some  form  in  197  cases,  and  that  in  14  of  these  the  peritoneum  was 
affected,  i.  e.,  lesions  of  tuberculosis  in  16.8  per  cent,  of  all  autopsies,  and  tuberculous 
peritonitis  in  7.1  per  cent,  of  these. 

Boltz,  quoted  by  Giuldjides,^"  examined  the  cadavers  of  176  tuberculous  children 
and  found  the  peritoneum  affected  in  27  instances,  or  15.3  per  cent.  O.  Miiller 
found  the  peritoneum  involved  in  27  of  150  cases,  or  18  per  cent.     Such  figures  as 

'Teleky,  L.:  "Die  Bauchfelltuberkulose  und  ihre  Behandlung,"  Centralbl.  f.  d.  Grenzgeb. 
d.  Med.  u.  Chir.,  Jena,  1899,  ii,  267-273;   326-328;   353-362. 

^Shattuck,  J.  C:  "On  Prognosis  and  Treatment  of  Tuberculous  Peritonitis,  Based  on  the 
Massachusetts  General  Hospital's  Experience  for  the  Past  Ten  Years"  (Abstract),  Am.  Med., 
Phila.,  1902,  iii,  808. 

^Loc.  cit. 

^Schroeder,  Emil:  "Beitrag  zur  Kenntniss  der  Peritoneal-Tuberkulose,"  Diss.  [Bonn.] 
Diisseldorf,  1897,  35. 

^Sutherland,  G.  A.:  "Prognosis  of  Tuberculous  Peritonitis  in  Children,"  Clin.  Jour.,  Lond., 
1903,  xxi,  189-192. 

^Hugentobler:  "Die  Peritonitis  tuberculosa  bei  interner  Behandlung,"  Diss.  Zurich,  1902,  56. 

'Engelmann:  "Beitrag  zur  Kenntniss  der  Bauchfellentzihidung,  besonders  der  tuberkulosen 
Form,"  Diss.  Munchen,  1902.  34. 

^Bottomley,  John  T.:  "A  Consideration  of  28  Cases  of  Tuberculous  Peritonitis  at  the  Boston 
City  Hospital,  with  Particular  Reference  to  the  Results  of  Operative  Treatment,"  Am.  Med., 
Phila.,  1902,  iii,  265-268. 

^Bottomley,  John  T.:  Idem.,  Boston  City  Hosp.  Rep.,  1900,  11  s.,  118-142. 
"Giuldjides,  Constantin:   "Ueber  Peritonitis  tuberculosa  und  ihre  Heilbarkeit  durch  Laparo- 
tomie,"  Diss.  Munchen,  61. 


620  TUBERCULOSIS    OF   THE    PERITONEUM. 

these  indicate  either  that  tuberculosis  of  the  peritoneum  per  se  is  more  common  in 
children  than  in  adults  or  that  the  lesions  of  tuberculosis  are  apt  to  be  more  easily 
disseminated  and  widespread  in  the  young. 

Primary  tuberculosis  of  the  peritoneum  is  very  rare,  and  that  it  ever  occurs  is 
denied  by  some  authorities.  From  our  present  knowledge  of  the  subject,  however, 
we  are  compelled  to  admit  its  possible  existence.  Bolhnger  estimates  that  it  occurs 
in  3  to  4  per  cent,  of  all  tuberculous  peritonitides.  Mazzoni  claimed  that  16  of  his 
35  operative  cases  were  primary.  Borschka,  on  the  other  hand,  from  the  study  of 
4250  autopsies  showing  1393  instances  of  tuberculosis  in  the  Pathological  Institute 
of  Breslau,  found  226  cases  of  tuberculous  peritonitis,  and  states  that  only  two  of 
these  226  cases  were,  without  a  doubt,  primary  in  the  peritoneum.  Seiffert,  quoted 
by  Ansinn,^  found  49  instances  of  primary  tuberculous  peritonitis  in  1317  cases  of 
tuberculosis  of  the  peritoneum,  or  3.7  per  cent. 

Age. — Tuberculosis  of  the  peritoneum  occurs  at  all  periods  of  life.  It  is  com- 
mon in  childhood,  relatively  rare  in  old  age.  Compiled  statistics  on  this  point  show 
that  the  affection  occurs  most  frequently  between  the  ages  of  twenty  and  forty,  al- 
though it  is  probable  that  the  percentage  in  childhood  would  be  larger  were  it  not 
for  the  fact  that  most  of  the  reported  statistics  are  of  cases  treated  surgically. 

Rotch^  states  that  tuberculous  peritonitis  may  occur  both  in  infancy  and  in  cliild- 
hood,  while  the  most  common  age  in  children  is  from  eighteen  months  to  four  years. 
DuvaP  finds  in  his  study  of  this  disease  in  childhood  that  the  majority  of  cases  occur 
from  six  to  twelve  years  of  age.  Giuldjides*  reports  that  of  1081  cases  of  tuberculous 
peritonitis  that  came  to  operation,  177  were  in  children,  or  16.3  per  cent.;  while 
Krencki^  has  compiled  from  the  literature  266  cases  that  were  operated  upon,  63 
cases,  or  23.5  per  cent.,  of  which  were  in  children. 

Osier''  has  added  to  his  21  cases,  69  of  Boulland,  48  of  Haene,  39  of  Maurange, 
and  45  of  Fenwick,  together  with  135  cases  of  Bristowe,  Hilton  Fagge,  and  Lebert; 
in  all,  357  cases.     These  are  arranged  according  to  age  as  follows: 

Under  10  years 27  cases 

75     " 


10  to  20 

20  to  30 

30  to  40 

40  to  50 

50  to  60 

60  to  70 

Above  70   " 

.71 
.61 
.19 
,  4 
,    2 


Sex. — The  opinion  of  various  authors  concerning  the  distribution  of  the  disease 
among  sexes  is  diametrically  opposed.     Surgeons  and  gynecologists  assert  that  the 

^Ansinn,  Kurt:  "Beitrage  zur  Behandlung  der  tuberculosen  Peritonitis  mittelst  der  Coelio- 
tomie,"  Diss.  Greifswald,  1903. 

^Rotch,  T.  M.:  "Tubercular  Peritonitis  in  Early  Life;  with  Especial  Reference  to  its  Treat- 
ment by  Laparotomy,"  Jour.  Am.  Med.  Assoc,  Chicago,  1903,  xl,  69-73. 

==  Duval:   "Peritonite  tuberculeuse,"  Prat,  med.-chir.  (etc.),  Par.,  1907,  v,  237-240. 

^  Loc.  cit. 

'Krencki,  J.  von:  "Ueber  die  Ausheilung  der  Peritoneal-tuberculose  durch  Laparotomie," 
Diss.  Konigsberg  i.  Pr.  1902,  169. 

'Loc.  cit. 


ETIOLOGY,  621 

female  sex  is  more  commonly  affected,  whereas  the  majority  of  pathologists  claim 
that  the  male  sex  is  more  subject  to  the  disease.  The  reason  for  this  lies  in  the  fact 
that  in  the  section  statistics,  or  in  the  compilation  of  cases,  of  those  treated  internally 
the  male  sex  is  represented  by  about  70  to  75  per  cent.,  while  the  statistical  results 
of  operative  cases  show  more  women  than  men. 

Adossides  found  among  1066  tuberculous  cadavers  766  men  and  only  300  women; 
Zahn,  1357  men  and  701  women  in  2058  cadavers.  Of  153  cases  collected  by  the 
pathologists  Phillips  and  Muenstermann,  122  were  in  men  and  31  in  women.  There 
is  one  possibility  of  error  which  should  be  eliminated  from  post-mortem  statistics, 
and  we  are  not  informed  if  that  was  done  in  the  above  series,  and  that  has  to  do  with 
the  relative  number  of  male  and  female  subjects  which  come  to  autopsy.  As  a 
general  rule,  many  more  males  than  females  are  subjected  to  autopsy,  and  unless 
this  fact  is  taken  into  consideration  such  sets  of  figures  are  much  invalidated. 

Operative  statistics  seem  to  show  that  the  disease  is  far  more  common  in  women 
than  in  men;  as,  for  example,  of  386  cases  reported  by  Konig,  Lindner,  Kiimmel, 
and  Roosenburg  (all  surgeons),  36  were  in  men  and  350  in  women. 

Giuldjides  is  of  the  opinion  that  in  spite  of  the  discrepancies  in  figures  the  disease 
is  de  facto  more  frequent  in  women  than  in  the  opposite  sex. 

As  regards  sex  in  children,  it  will  be  seen  that  it  plays  no  part  of  special  impor- 
tance. Of  186  cases  in  children  reported  by  Schnitz,  Boltz,  Fink,  Frick,  Gassel, 
and  Rotch,  96  were  boys  and  90  were  girls, 

Nothnagel  says:  "Sex  plays  a  peculiar  role  in  our  statistics;  among  the  cases 
discovered  after  death  there  are  many  more  males,  none  of  whom  died  after  opera- 
tion, while  among  the  subjects  who  were  operated  upon  for  the  disease  many  more 
women  (90  per  cent.)  were  found.  This  is  probably  due  to  the  fact  that  in  women 
operations  are  more  often  performed  because  some  other  diagnosis  is  more  com- 
monly made — diseases  of  the  sexual  organs. " 

Factors  Governing  Infection, — The  same  factors  which  predispose  to  tuber- 
culosis in  general  also  obtain  as  regards  the  form  of  the  infection  involving  the  peri- 
toneal membranes.  These  include:  (a)  the  family  history  of  tuberculosis;  (h) 
poor  hygienic  environment,  especially  during  infancy;  (c)  a  constitution  of  feeble 
resistant  power;  (o^)  a  severe  infective  illness  in  early  life;  {e)  chronic  diseases  of 
the  kidney,  liver,  blood-vessels,  etc.,  in  which  tuberculosis  of  the  serous  membranes 
is  not  uncommonly  a  terminal  event. 

The  exciting  cause  of  tuberculosis  of  the  peritoneum  is  the  invasion  of  the  serous 
membrane  by  the  bacillus  of  Koch.  In  view  of  the  bactericidal  property  of  the  peri- 
toneal fluid,  which,  according  to  Notzel,  is  apparently  greater  than  that  of  the  blood- 
serum,  the  predisposition  of  this  cavity  to  tuberculous  infection  is  slight.  Dimin- 
ished peristalsis  is  said  to  favor  the  foothold  of  the  tubercle  bacillus  by  retarding 
the  dissemination  of  the  micro-organisms  so  as  to  be  acted  upon  by  the  protective 
secretions. 

Striimpell  and  Osier  both  believe  that  chronic  intestinal  catarrh  is  a  predisposing 
cause,  especially  in  children. 


622  TUBERCULOSIS    OF   THE    PERITONEUM. 

Stasis  of  the  portal  system  has  been  thought  by  some  writers  to  favor  the  occur- 
rence of  tuberculous  peritonitis  because  of  the  frequent  association  of  this  disease 
with  cirrhosis  of  the  hver.  Some  authors  consider  tuberculosis  of  the  peritoneum 
primary  in  this  class  of  cases,  and  beheve  that  the  growth  of  interstitial  tissue  in 
the  liver  emanates  from  the  tuberculous  capsule  and  only  secondarily  invades  the 
liver  substance.  Weigert  and  Chiari,  on  the  contrary,  hold  that  the  cirrhosis  of  the 
liver  is  primary,  and  that  the  resulting  ascites  furnishes  a  favorable  culture-medium 
for  the  growth  of  bacilli  which  enter  the  abdominal  cavity.  A  priori  one  would 
suppose  that  a  certain  degree  of  venous  stasis  would  be  inimical  to  the  lodgment  and 
flourishing  of  the  tubercle  bacillus,  reasoning  by  analogy  from  the  briUiant  results 
obtained  in  tuberculous  arthritis  and  other  forms  of  infection  by  the  artificial  stasis 
secured  by  the  employment  of  Bier's  methods  of  treatment.  It  seems  much  simpler 
to  attribute  the  occurrence  of  tuberculosis  of  the  peritoneum  in  hepatic  and  other 
chronic  disorders  to  the  lowered  resistance  in  the  individual  who  is  so  affected.  In 
this  same  manner  can  be  explained  the  views  of  Courtois-Suffit  and  others  who  look 
upon  alcoholism  as  the  predisposing  cause,  as  it  is  so  frequently  associated  with 
tuberculous  peritonitis  and  hepatic  cirrhosis. 

In  many  instances  the  peritoneal  lesions  are  secondary  to  tuberculosis  of  the 
intestine,  and  in  all  cases  of  tuberculous  ulceration  of  the  gut  small  yellow  tubercles 
can  be  demonstrated  lying  just  beneath  the  serous  surface  of  the  ulcerated  areas. 
It  has  been  frequently  shown,  however,  that  tubercle  bacilH  maf  pass  through  the 
intestinal  wall  without  producing  any  lesions.  Most  interesting  in  this  connection 
are  the  experiments  of  Ravenel.^  He  fed  fasting  animals  with  a  mixture  of  tubercle 
bacilli  and  butter,  and  three  and  one-half  hours  later  examined  the  thoracic  duct 
and  mesenteric  glands  by  inoculation,  and  demonstrated  the  presence  of  tubercle 
bacilli  in  these  structures.  Working  along  this  same  fine,  Whipple^  was  able  to 
demonstrate  tubercle  bacilli  in  smears  made  from  the  contents  of  the  thoracic  duct 
in  16  out  of  27  cases  of  various  forms  of  tuberculosis  that  came  to  autopsy. 

In  the  largest  number  of  cases,  says  Nothnagel,  the  lungs  are  primarily  affected, 
while  no  other  abdominal  organ  except  the  peritoneum  shares  in  the  infection.  In 
some  cases  tuberculosis  of  the  peritoneum  follows  a  glandular  tuberculosis;  in  a 
large  number  of  cases,  perhaps  in  the  majority,  the  condition  is  associated  with  tu- 
berculous infection  of  the  pleura.  In  other  cases,  again,  the  tubercle  bacillus  dis- 
plays a  special  preference  for  the  serous  membranes,  and  we  find  the  pericardium, 
pleura,  and  meninges  also  involved  in  the  tuberculous  process. 

Primary  tuberculosis  of  the  genitalia  plays  an  important  part  in  the  etiology  of 
tuberculous  peritonitis,  particularly  in  women.  Phillips,  Mazzoni,  Borschka,  and 
Sick  collected  414  cases  of  tuberculosis  of  the  peritoneum  in  which  the  primary 
focus  occurred  47  times  in  the  genitalia  of  women  and  27  times  in  the  genitalia  of 
men.     Phthisis  was  also  present  in  81.8  per  cent,  of  these  414  cases.     In  77  cases 

'Ravenel,  Mazyck  P.:  "The  Passage  of  Tubercle  Bacilli  through  the  Normal  Intestinal  Wall. 
(A  preliminary  report.)"     Jour.  Med.  Research,  Boston,  1903,  n.  s.,  v,  460-462. 

2  Whipple,  G.  H.:  "Disseminated  Tuberculosis  in  Relation  to  the  Thoracic  Duct  and  Vascular 
Tubercles,"  Johns  Hopkins.  Hosp.  Bull.,  Balto.,  1906,  xvii,  270-272. 


PATHOLOGY.  623 

collected  by  Frees,  Hegar,  Zweifel,  Casivari,  Spaeth,  Lohlein,  Gerard-Marchant, 
Edebohls,  and  Kiistner,  the  primary  focus  was  in  the  genitalia  in  33  of  the  cases, 
about  42  per  cent.  Aldibert  found  primary  tuberculosis  of  the  genitalia  in  56  per 
cent,  and  Adossides  in  63  per  cent,  of  their  cases.  Tuberculous  salpingitis,  or  the 
infection  of  the  uterus,  vagina,  or  ovaries,  can  all  be  the  starting-point  of  the  peri- 
tonitis in  women,  while  in  men  tuberculous  disease  of  the  epididymis  or  seminal 
vesicles  may  play  a  like  role. 

PATHOLOGY. 

Tuberculosis  of  the  peritoneum  may  be  divided  according  to  its  pathologic 
anatomy  into  acute  and  chronic  types.  The  acute  form  of  the  disease  has  as  its 
anatomic  picture  a  general  dissemination  of  miliary  tubercles  involving  the  parietal 
and  visceral  layers  of  the  peritoneum.  The  chronic  type  is  subdivided  into  an 
ulceradve  or  suppurative  form,  and  a  fibrous  or  adhesive  form.  This  is  the  usual 
classificadon  adopted  by  American  writers.  The  majority  of  French  authors  classify 
tuberculous  peritonids  as  follows:  (1)  Mihary  form.  (2)  Fibrous  form:  (a)  dry 
fibrous  form;  (b)  free  ascitic  form;  (c)  ascitic  encysted  form.  (3)  Ulcerous,  or 
caseous,  form:  (a)  dry  caseous  form;  (b)  caseous  purulent  form.  Most  German 
writers  on  the  subject  recognize:  (1)  Exudadve  type  with  (a)  free  ascites  and 
(fe)  locahzed  ascites;  and  (2)  the  dry  type  of  the  disease. 

In  the  acute  miliary  tuberculosis  of  the  peritoneum  the  serous  membrane  covering 
the  intesdnes,  omentum,  mesentery,  and  the  various  organs  in  the  abdomen,  as  well 
as  the  parietal  peritoneum,  are  studded  with  numerous  small  yellowish  tubercles. 
These  vary  in  size  from  0.5  to  5  mm.  in  diameter,  are  for  the  most  part  discrete, 
and  are  superficially  situated.  The  tubercles  are  most  numerous  on  the  serous  sur- 
face of  the  intestines  and  in  the  omentum  and  mesentery,  but  are  especially  thick 
in  the  capsules  of  the  liver  and  spleen.  As  a  rule,  the  intestines  are  not  matted 
together  nor  is  the  abdominal  cavity  parddoned  off.  An  excess  of  fluid  is  almost 
always  found  and,  according  to  the  majority  of  authors,  the  abdomen  regularly  con- 
tains a  considerable  amount  of  exudate,  consisdng  of  citrinous  serum,  often  sero- 
fibrinous, sometimes  sanguineous,  rarely  sero-purulent.  Some  writers  do  not  beheve 
that  this  form  of  peritonitis  is  always  associated  with  ascites,  and  among  these  are 
Borschka,  who  found  among  16  cases  of  miliary  tuberculosis  in  his  series  of  226 
cases  only  two  which  showed  a  serous  exudate. 

In  the  chronic  ulcerative  forms  of  tuberculosis  of  the  peritoneum  the  serous  mem- 
brane is  covered  with  a  false  membrane  of  soft,  yellowish  consistency.  This  exudate 
may  be  converted  in  places  into  cicatricial  masses,  so  that  the  loops  of  intestine 
become  agglutinated  by  the  fibrous  material  or  become  adherent  to  the  abdominal 
wall,  liver,  spleen,  and  pelvic  organs.  The  adherent  coils  of  intestine  often  cause 
the  exudate  to  become  sacculated,  and  on  opening  such  an  accumulation  of  fluid 
it  is  often  found  to  be  of  a  purulent  nature,  and  may  be  of  a  chocolate  color,  due 
to  its  mixture  with  altered  blood.  Encysted  foci  are  encountered  in  various  parts 
of  the  abdominal  cavity  and  give  rise  to  large  tumor-like  masses.     Very  remark- 


624  TUBERCULOSIS    OF   THE   PEEITONEUM. 

able  examples  of  this  are  seen  in  certain  instances  in  which  the  exudate  is  con- 
fined to  the  lesser  peritoneal  cavity,  as  the  foramen  of  Winslow  becomes  closed  by 
exudate,  and  a  large  rounded  tumor  appears  in  the  epigastrium  or  mid-abdomen. 
The  mesenteric  glands  are  always  affected  and  the  process  often  extends  to  the 
pleura,  pericardium,  and  lungs.  The  intestinal  walls  are  usually  much  infiltrated 
and  are  friable  and  easily  torn.  This  form  of  tuberculosis  is  essentially  ulcerative 
and  is  prone  to  cause  either  a  perforation  of  the  intestine,  forming  a  cloaca  infected 
with  a  mixture  of  intestinal  and  peritoneal  fluids,  or  the  ulceration  may  lead  to  the 
formation  of  an  external  fistula,  most  often  at  or  near  the  umbilicus.  The  tendency 
of  this  form  of  peritonitis  is  to  ulceration  and  the  formation  of  cicatricial  tissue,  so 
that  spontaneous  cure  is  exceptional. 

Chronic  fibrous  tuberculosis  of  the  peritoneum  may  be  subacute  from  the  outset 
or  may  represent  the  final  stage  of  the  acute  miliary  form  of  the  disease.  In  the 
early  stages  of  this  form  the  abdomen  contains  a  moderate  or  an  abundant  amount 
of  exudate,  which  is  yellow  in  color  and  of  a  serous  consistency,  but  may  be  san- 
guinolent  or  sero-purulent.  The  fluid  at  first  is  free  in  the  peritoneal  cavity,  while  the 
tubercles  on  the  serous  surfaces  are  usually  hard  and  pigmented.  As  the  process 
advances,  however,  vascular  granulations  lead  to  the  formation  of  connective  tissue. 
Hence  cicatricial  contractions  occur,  adhesions  form  in  the  peritoneal  folds,  por- 
tions of  the  exudate  may  become  encapsulated,  the  omentum  is  often  contracted 
into  a  tough,  thick  cord  lying  transversely  across  the  epigastrium  so  as  to  form  a 
prominent  tumor  mass,  and  the  scarring  and  contraction  of  the  mesentery  may  draw 
the  intestine  into  a  small  knot  against  the  spinal  column.  If  the  cicatricial  process 
develops  more  rapidly  than  the  tuberculous  growth,  the  latter  may  be  well  encap- 
sulated by  fibrous  tissue,  and  spontaneous  cure  ensue  here  just  as  it  does  in  the 
lungs  or  other  organs  which  are  the  seat  of  tuberculous  disease.  The  exudate  then 
disappears,  resulting  in  the  dry  form  of  the  disease. 


SYMPTOMATOLOGY. 

The  clinical  manifestations  of  tuberculosis  of  the  peritoneum  are  very  variable, 
so  as  to  present  a  "symptom-complex  of  extraordinary  diversity."  The  disease 
may  run  an  acute,  a  subacute,  or  a  chronic  course,  while  in  other  instances  it  is 
entirely  latent. 

In  the  latent  form  there  is  often  not  the  slightest  suspicion  of  tuberculosis  enter- 
tained, and  the  condition  becomes  known  only  when  the  abdomen  is  opened  for 
other  reasons.  Every  gynecologist  has  had  this  experience,  and  it  is  in  just  these 
cases  that  the  operator  should  carefully  look  for  a  primary  focus,  especially  in  the 
adnexa. 

The  acute  type  of  tuberculous  peritonitis  may  set  in  very  suddenly  in  an  individ- 
ual previously  free  from  all  abdominal  symptoms.  In  such  instances  the  usual 
diagnosis  is  strangulated  hernia  or  acute  appendicitis,  so  that  the  patients  have  come 
to  operation  at  once.     In  other  cases  of  the  acute  type  the  patient  may  present  all 


SYMPTOMATOLOGY.  625 

the  features  of  an  active  septicemia,  ciiills,  irregular  fever,  and  sweats,  with  few  if 
any  signs  directing  attention  to  the  abdomen,  so  that  the  diagnosis  is  made  with  much 
difficulty,  or,  indeed,  is  often  deferred  until  some  localizing  symptom  makes  its 
appearance.  The  careful  study  of  the  blood  is  of  particular  value  in  arri\nng  at  a 
conclusion  in  this  class  of  cases,  while  the  discovery  of  an  enlarged,  nodular  epididy- 
mis, a  pleural  friction,  or  an  infiltrated  apex  often  gives  the  clue  to  the  situation. 

The  most  common  form  of  tuberculous  peritonitis  one  meets  with  falls  into  the 
category  of  the  subacute  type.  The  cHnical  picture  is  quite  definite,  as  a  rule,  and 
the  diagnosis  is  usually  made.  There  are  cases,  however,  to  which  Osier  and  others 
have  called  attention,  which,  with  a  slow  onset,  abdominal  tenderness,  persistent 
tympanites,  and  a  low  continuous  fever,  simulate  typhoid  fever  most  accurately. 
The  blood  picture,  too,  resembles  that  found  in  enteric  fever,  and  a  positive  diazo 
reaction  is  frequently  obtained.  The  ^Yidal  test,  however,  is  continuously  negative, 
but  it  is  just  here  that  the  serum  reaction  does  not  help  us,  as  it  may  be  absent  in 
from  3  to  8  per  cent,  of  all  typhoid  infections.  Recently  the  extended  employment 
of  blood  cultures  has  proved  of  distinct  value  in  excluding  typhoid  fever  and  other 
forms  of  septicemia.  Tuberculin  is  of  the  greatest  value  as  a  means  of  diagnosis 
and  should  be  used  in  all  clinically  doubtful  cases. 

Chronic  Tuberculous  Peritonitis. — The  ordinary  type  of  subacute  tuberculous 
peritonitis  merges  into  the  chronic  form,  so  that  they  can  be  best  described  together. 
In  general,  the  constitutional  symptoms  consist  of  weakness,  loss  of  weight,  anorexia 
and  perhaps  vomiting,  and  intestinal  derangement.  As  a  rule,  there  is  constipa- 
tion, which,  indeed,  may  be  marked,  while  if  diarrhea  is  present  it  is  usually  associ- 
ated with  tuberculous  ulceration  in  the  intestine.  Fever  may  or  may  not  be  present. 
The  majority  of  cases  run  a  slight  irregular  temperature,  but  in  some  instances  the 
temperature  curve  may  be  subnormal  over  long  periods  of  time,  an  expression  of 
the  lowered  state  of  nutrition  with  a  non-active  inflammatory  process.  An  early 
symptom  is  abdominal  discomfort,  which  is  more  or  less  persistent  and  may  develop 
into  actual  pain,  either  general  or  locahzed.  The  anatomic  picture,  post  mortem, 
is  very  often  out  of  all  proportion  to  the  subjective  symptoms  noted  during  hfe. 
Tympanites  is  a  common  sjnnptom  and  is  most  often  due  to  the  loss  of  muscular 
tone  in  the  infiltrated  intestinal  walls,  although  it  may  be  caused  by  partial  constric- 
tion due  to  adhesions  or  to  excessive  fermentative  changes  in  the  intestinal  contents, 
particularly  if  there  is  an  associated  intestinal  tuberculosis.  In  some  instances  there 
is  a  striking  pigmentation  of  the  skin,  even  without  involvement  of  the  adrenals, 
so  as  to  suggest  the  diagnosis  of  Addison's  disease.  A  periomphahtis,  or- inflamma- 
tion in  the  neighborhood  of  the  navel,  when  it  occurs,  is  of  considerable  diagnostic 
importance. 

The  two  most  valuable  signs  of  tuberculosis  of  the  peritoneum  have  to  do  with 
the  presence  of  an  exudate  and  with  tumor  formation.  Ascites  almost  always  ac- 
companies this  form  of  inflammation  of  the  peritoneal  membranes. 

In  most  instances  the  amount  of  effusion  is  moderate,  but  it  may  be  so  abundant 
as  to  cause  marked  distention,  and  so  induce  considerable  embarrassment  of  the 
VOL.  II — 40 


626  TUBERCULOSIS    OF   THE    PERITONEUM. 

heart  and  respiratory  apparatus.  The  fluid  is  usually  serous,  of  a  bright  yellow  or 
straw  color,  contains  albumin,  usually  coagulates  spontaneously  on  standing;  the 
cellular  elements  consist  of  desquamated  endothelial  cells  and  mononuclear  leuko- 
cytes; occasionally  red  blood-cells  and  pus-cells  are  also  present.  The  fluid  con- 
tains the  offending  micro-organisms  in  smafl  numbers,  as  they  may  sometimes  be 
found  by  the  inoscopic  method  suggested  by  Jousset,^  and  have  also  been  isolated 
by  inoculation.  The  effusion  may  be  sero-fibrinous  or  hemorrhagic,  or  at  times 
purulent.  The  fluid  is  often  free,  but  it  may  be  encapsulated  in  various  regions 
within  the  abdomen. 

The  tumor  formations  may  be  due  to  several  causes.  In  the  first  place,  the 
sacculated  exudations  just  mentioned  give  rise  to  small  or  large  swelhngs,  which 
are  usually  rounded,  of  a  firm  consistence,  and  not,  as  a  rule,  movable.  The  en- 
cysted exudate  is  most  commonly  found  in  the  middle  zone,  where  it  may  be  mis- 
taken for  an  ovarian  cyst;  another  rather  frequent  situation  is  in  the  lesser  peritoneal 
sac,  forming  a  large  rounded  mass  in  the  epigastrium  lying  more  on  the  left  side 
than  on  the  right.  Associated  with  tuberculous  disease  of  the  Fallopian  tubes  the 
sacculated  exudate  may  lie  entirely  within  the  pelvis  proper.  A  second  form  of 
tumor  is  that  due  to  a  thickened,  rolled-up  omentum,  wliich  then  lies  as  a  sausage- 
shaped  mass  transversely  across  the  abdomen  just  above  the  level  of  the  umbilicus. 
This  is  the  most  constantly  found  variety  of  tumor  mass  in  tuberculous  peritonitis, 
but  a  similar  rolling  of  the  omentum  may  occur  in  peritoneal  carcinomatosis.  A 
third  form  of  tumor  formation,  which  is  quite  rare  as  compared  with  the  preceding 
two,  is  due  to  infiltration  and  cicatrization  of  the  mesentery,  which,  by  its  contrac- 
tion, draws  the  intestines  into  a  knot  down  against  the  spinal  column,  and,  together 
with  the  great  thickening  of  the  walls  of  the  intestines,  forms  a  more  or  less  firm, 
scarcely  movable  mass. 

A  fourth  form  of  tumor  growth  is  found  most  frequendy  in  children,  giving  rise 
to  the  condition  commonly  known  as  tabes  mesenterica,  and  is  caused  by  the  in- 
volvement of  the  mesenteric  and  retroperitoneal  glands  in  the  tuberculous  process. 
The  recognition  of  these  tumor  formations  is  often  rendered  diflficult  in  the  presence 
of  ascites,  but  if  the  abdomen  is  tapped  they  can  usually  be  mapped  out  without 
difficulty. 

DIAGNOSIS. 
In  probably  the  majority  of  cases  the  diagnosis  is  correctly  made  when  the  pa- 
tient is  first  seen,  at  least  in  the  subacute  and  chronic  forms  of  tuberculosis  of  the 
peritoneum.     The  chief  points  of  value  in  arriving  at  this  conclusion  may  be  con- 
veniently arranged  as  follows: 

1.  The  history  of  a  family  tendency  to  tuberculosis  is  of  some  importance  as  a 
predisposing  factor  to  the  infection. 

2.  The  presence  of  a  tuberculous  lesion  elsewhere  in  the  body  is  very  strong  evi- 

1  Jousset,  Andre:  "Nouvelle  methode  pour  isoler  le  bacille  de  Koch  des  humeurs  de  I'or- 
ganisme,"  Semaine  med.,  Par.,  1903,  xxiii,  22-24. 


DIFFERENTIAL    DIAGNOSIS.  627 

dence  that  any  irritative  signs  occurring  in  the  abdominal  cavity  have  a  hke  etiology. 
In  this  connection  it  may  be  stated  that  the  simultaneous  inflammation  of  any  two 
serous  sacs  of  the  body  is  almost  always  of  tuberculous  origin.  The  occurrence  of 
salpingitis  in  the  female,  or  of  a  nodular  epididymitis  or  seminal  vesiculitis  in  the 
male,  may  give  the  clue. 

3.  The  general  state  of  nutrition  is  usually  much  impaired,  although  the  affec- 
tion may  attack  an  apparently  robust  individual.  Special  features  associated  with 
malnutrition  are  the  anorexia,  intestinal  disturbances,  and  abdominal  discomfort. 

4.  The  examination  of  the  abdomen  usually  reveals  the  presence  of  an  effusion. 
If  this  is  withdrawn,  or  if,  without  tapping,  one  is  able  to  make  out  multiple  masses, 
the  diagnosis  is  at  once  limited  to  either  tuberculosis  or  mahgnant  new-growth  with 
metastases. 

5.  Among  the  special  examinations  that  may  be  employed  to  advantage  are:  (a) 
The  tuberculin  test.  In  a  clinically  doubtful  case  it  is  quite  feasible  to  employ  tu- 
berculin if  the  patient  is  afebrile.  The  dose  at  first  should  be  small,  certainly  not 
over  one  milligram,  as  the  resulting  reaction  in  a  positive  case  may  be  marked. 
This  is  a  most  valuable  diagnostic  procedure,  and  Halsted,  of  Baltimore,  says  that 
he  has  never  known  it  to  fail  in  cases  of  tuberculous  peritonitis,  (b)  The  diazo  reac- 
tion of  the  urine  is  given  as  constantly  in  tuberculosis  of  the  peritoneum  as,  if  not 
more  so  than,  in  typhoid  fever,  and  a  marked  positive  test  is  strong  corroborative 
evidence,  (c)  The  examination  of  the  blood  shows  a  mild  grade  of  secondary 
anemia,  except  in  those  cases  in  which  the  blood  may  be  concentrated  by  diarrhea. 
As  a  rule,  the  leukocytes  are  not  increased,  and  if  a  leukocytosis  does  occur,  it 
is  the  result  of  a  secondary  infection.  In  the  usual  run  of  cases  the  differential 
count  is  either  normal  or  may  show  a  relative  increase  in  the  mononuclear  elements 
commonly  found  in  all  conditions  of  poor  nutrition,  (d)  The  examination  of  the 
ascitic  fluid  has  shown  that  the  study  of  the  cellular  elements  is  of  practically  no 
aid  in  making  a  diagnosis,  as  the  character  of  the  fluid  in  this  respect  does  not  differ 
from  that  produced  by  certain  other  conditions  associated  with  a  peritoneal  effu- 
sion. Tubercle  bacilli  are  present  in  the  exudate,  but  in  such  small  numbers  as 
sometimes  to  escape  even  the  inoculation  test. 

6.  In  clinically  obscure  cases,  when  all  other  means  of  arriving  at  a  conclusion 
have  been  tried,  a  simple  exploratory  operation  is  amply  justified. 


DIFFERENTIAL  DIAGNOSIS. 

The  chief  difficulties  that  one  encounters  in  making  a  correct  diagnosis  are  in 
connection  with  the  following  conditions : 

1.  Ascites  associated  with  cirrhosis  of  the  liver.  Fever  and  pain  may  be  equally 
absent  in  both  affections,  and  even  the  fact  that  after  paracentesis  the  liver  is  found 
to  be  diminished  in  size  does  not  alone  decide  the  question,  for  the  two  affections 
may  occur  together,  the  hepatic  cirrhosis  either  favoring  the  development  of  the 
tuberculous  peritonitis,  or  the  cirrhosis  developing  as  the  result  of  the  peritonitis. 


628  TUBERCULOSIS    OF   THE    PERITONEUM. 

The  chief  points  in  favor  of  the  cirrhosis  are  to  be  found  in  the  alcohoHc  history,  the 
collateral  venous  circulation,  the  indolence  of  the  abdomen,  splenomegaly,  and  the 
frequent  occurrence  of  hemorrhoids  and  of  epistaxis.  Syphilis  of  the  Kver  is  nearly 
always  accompanied  by  an  enlargement  of  this  organ,  but  in  the  later  stage  one  may 
find  a  shrunken,  scarred  hver,  as  in  the  cirrhosis  of  Laennec,  and  it  is  with  this  form 
that  tuberculous  peritonitis  may  be  confounded. 

2.  Abdominal  tumors  not  due  to  tuberculosis.  These  may  arise  in  any  of  the 
abdominal  organs,  stomach,  intestine,  gall-bladder,  kidney,  glands,  female  gener- 
ative organs,  etc.  These  growths,  as  a  rule,  are  single;  so  also,  of  course,  may  be 
the  tuberculous  tumor.  The  most  easily  palpable  tuberculous  mass,  the  rolled-up 
omentum,  is  of  such  characteristic  shape  and  position  that  the  diagnosis  will  be 
instinctively  first  directed  toward  tuberculosis.  In  order  to  differentiate  this  tumor 
from  a  gastric  carcinoma  the  chemical  reaction  of  the  gastric  secretion  must  be  in- 
vestigated. Cysts  of  the  ovary  have  frequently  been  mistaken  for  tuberculous  masses, 
and  vice  versa.  In  ovarian  cysts,  however,  the  fluid  is  not  usually  as  free  and  is  of 
a  different  character,  the  abdomen  is  uneven  and  more  prominent  anteriorly,  and 
the  intestinal  tympany  is  present  in  the  flanks,  while  the  percussion  note  is  dull  at 
the  higher  points.  Sometimes,  however,  the  differential  diagnosis  is  not  easily  at- 
tained in  these  cases. 

3.  A  far  less  pardonable  mistake  is  sometimes  made  by  operating  upon  an  indi- 
vidual who  is  subject  of  a  purely  neurotic  disorder.  It  is  sometimes  puzzling  to  dis- 
tinguish the  pain,  abdominal  tenderness,  flatulence,  constipation,  etc.,  of  an  intensely 
neurotic  woman  from  a  true  organic  lesion.  That  these  patients  are  not  infrequently 
needlessly  subjected  to  surgical  procedures  has  been  often  written  of  by  Dubois^ 
and  others.  The  most  consummate  skill  is  often  required  to  recognize  the  hysteri- 
cal stigmata  so  as  not  to  be  misled  in  these  not  uncommon  cases. 


PROGNOSIS. 
Until  1884,  when  Konig  first  proposed  surgical  intervention  for  the  cure  of  tuber- 
culosis of  the  peritoneum,  the  gravest  apprehensions  were  entertained  in  regard  to 
this  disease;  indeed,  it  was  considered  almost  invariably  fatal.  Up  to  this  time  all 
instances  of  spontaneous  cure  were  looked  upon  as  mistakes  in  diagnosis.  The 
great  impetus  that  was  given  to  the  study  of  this  affection  in  the  next  succeeding 
years  brought  forth  undoubted  cases  of  tuberculosis  of  the  peritoneum  that  spon- 
taneously resolved.  This  happy  event  seems  to  be  not  uncommon  in  children, 
according  to  Chaffee  and  Hilton  Fagge,  while  Nothnagel,  Nassauer,  Marfan,  and 
many  others  have  shown  that  there  is  a  tendency  to  healing  in  many  cases  in  adults, 
and  that  spontaneous  cure  does  occur.  Probably  the  first  positive  proof  of  this 
was  the  case  of  tuberculous  peritonitis  seen  at  operation  by  Hegar,  in  which,  on  the 
occasion  of  a  later  laparotomy, ,  all  signs  of  the  pre-existing  lesions  had  entirely 
disappeared. 

1  Dubois,  P.:  "The  Psychic  Treatment  of  Nervous  Disorders,"  1906,  New  York. 


PROGNOSIS. 


629 


After  the  treatment  by  celiotomy  was  instituted,  surgical  intervention  was  looked 
upon  as  a  panacea  for  this  hitherto  hopeless  affection,  and,  heedless  of  a  few  dissent- 
ing voices,  surgeons  all  over  the  world  began  to  operate  for  this  condition,  and  for 
the  next  fifteen  years — until  1899 — reported  recoveries  in  from  70  to  85  per  cent, 
of  their  cases.  The  time  of  observation  was  far  too  short,  however,  in  these  series 
collected  from  the  literature,  because  cases  were  included  that  had  been  operated 
on  for  only  a  few  months.  For  example,  Cellier  reported  71  per  cent,  of  recoveries 
in  a  total  of  287  cases  shortly  after  operation,  which  dwindled  down  to  25  per  cent, 
when  the  patients  had  been  under  observation  for  two  years  or  more.  Many  authors, 
including  von  Winckel,  Halsted,  and  others,  do  not  consider  that  a  patient  can  be 
said  to  have  recovered  from  the  disease  unless  he  has  survived  for  five  years,  and 
this,  of  course,  applies  to  those  treated  medicinally  as  well  as  to  those  operated  upon. 
Having  in  mind  that  the  vast  majority  of  statistics  bearing  on  the  subject  are  to  a 
certain  degree  misleading,  we  may  now  discuss  the  prognosis  according  to  the  two 
methods  of  treatment,  hoping  that  in  the  course  of  the  next  few  years  we  may  be 
able  to  speak  with  more  certainty. 

The  Prognosis  as  Affected  by  Surgical  Treatment. — Giuldjides,^  in  1902, 
was  able  to  collect  1081  cases  of  tuberculosis  of  the  peritoneum  that  had  been  treated 
by  laparotomy  with  778  cures,  or  72  per  cent.  These  were  compiled  from  the  follow- 
ino;  authors : 


Authors. 

Cases. 

Cures. 

Per  Cent. 
Recoveries. 

Adossides 

405 

3 
24 

7 
14 
23 

2 
16 
18 

7 
30 
12 
29 
19 

4 
35 

7 
14 

2 

253 

35 

2 
40 
43 
13 

3 
19 

2 

278 
3 

16 
6 
9 

14 
2 

10 
6 
4 

19 
7 

18 
9 
4 

27 
5 

10 

2 

216 

33 
2 

25 

29 

7 

3 

12 

2 

69 

Bartz 

100 

Baumgarten 

67 

Beaussenat 

86 

Ebstein 

64 

Ferri 

61 

Fink 

100 

Firchau .• 

63 

Frees 

33 

Gassel 

57 

Gluck 

63 

Gross 

Hertzfeld 

58 
62 

Hintenberger 

47 

Israel 

100 

Kissel 

77 

Knapmann 

71 

Lauper 

71 

Lejars. . 

100 

Margarucci 

85 

Mazzoni .    .        

97 

Merkel 

100 

Psaltoff 

63 

Sadillo 

67 

Scheuer 

54 

D'Urso 

100 

Valenta,  Jun 

63 

Warneck 

100 

Total 

1081 

778 

72 

'  Loc.  cit. 


630 


TUBERCULOSIS    OF   THE    PERITONEUM. 


A  similarly  arranged  set  of  statistics  compiled  from  American  operators  shows 
294  cases  of  tuberculous  peritonitis  subjected  to  operation  with  233  recorded  recov- 
eries, or  79  per  cent.,  as  follows: 


Authors. 

Cases. 

Cures. 

Per  Cent. 
Recoveries. 

Abbe                                

2 
28 
10 
110    ■ 
21 
26 
32 
32 
52 

2 
11 

7 
90 
17 
25 
15 
20 
46 

100 

39 

70 

Hall                                          

82 

81 

Mavo                              

96 

47 

T?  ntoh                                   • 

63 

88 

Total                            

294 

233 

79 

Halstead,^  writing  in  1903,  calls  attention  to  the  fact  that  up  to  that  time  over 
1500  cases  of  peritoneal  tuberculosis  treated  by  laparotomy  have  been  recorded. 
From  these  reports  it  is  evident  that  the  prognosis  depends  largely  upon  the  anato- 
mic form  of  the  disease.  In  the  exudative  or  ascitic  form  the  prognosis  is  most 
favorable,  and  he  places  a  conservative  estimate  of  40  to  50  per  cent,  of  cures  in 
this  type.  The  adhesive  form  gives  a  more  unfavorable  prognosis  in  that  at  most  only 
about  25  per  cent,  recover.  In  the  ulcerative  caseating  variety  the  benefit  of  laparo- 
tomv  is  questionable.  More  carefully  prepared  statistics  are  those  of  Wunderlich.^ 
He  has  compiled  500  cases  of  tuberculous  peritonitis  which  have  been  treated  surgi- 
cally and  in  which  a  more  or  less  complete  history  of  each  case  is  given.  The  results 
in  these  cases  have  all  been  noted  at  a  period  of  three  years  or  more  since  operation, 
and  he  summarizes  the  results  as  follows : 

Ascitic  form 344  cases,  68.8%.     Cures  in  23.3%. 

Fibro-adhesive  form 136      "       27.2%,.         "       "     9.8%. 

Ulcerative  form 20      "         4.0%.     Cures  none. 

The  chief  factor  in  the  prognosis  of  surgically  treated  peritoneal  tuberculosis  has 
to  do  with  the  removal  of  the  primary  focus  of  the  disease.  If  this  is  localized  and 
can  be  extirpated,  the  chances  for  recovery  are  of  the  best.  Aside  from  this,  the 
prognosis  is  much  more  serious,  and  in  complicated  forms  of  tuberculous  peritonitis 
the  prospect  may  be  much  changed  by  meddlesome  surgical  interference.  The 
conclusions  of  Sutherland's  paper  (loc.  cit.)  have  to  do  particularly  with  the  factors 
of  prognosis,  and  are  as  follows : 

1.  In  uncomplicated  tuberculous  peritonitis  the  prognosis  is  good. 

2.  When  tuberculous  pleurisy  is  present  the  prognosis  is  still  favorable. 

3.  The  prognosis  is  rendered  less  favorable  in  the  case  of  (a)  a  strong  family 
history  of  tuberculosis;   (b)  an  infancy  passed  under  bad  hygienic  conditions;   (c) 

1  Halstead,  A.  E.:  "Tuberculous  Peritonitis,"  Am.  Med.,  Phila.,  1903,  v,  176-179. 
MVunderlich,  Otto:  "Ueber  die  Misserfolge  der  operativen  Behandlung  der  Bauchfelltuber- 
culose,"  Arch.  f.  Gynak.,  Berl.,  1899,  lix,  216-276. 


PROGNOSIS.  631 

a  constitution  of  feeble  resistant  power;    (d)  or  a  history  of  severe  infective  illness 
in  early  life. 

4.  The  prognosis  is  rendered  less  favorable  in  the  presence  of  one  or  more  of  the 
following  symptoms:  continuous  pyrexia,  rapid  wasting,  persistent  diarrhea,  rapid 
pulse,  and  recurrent  acute  exacerbations. 

5.  It  is  rendered  less  favorable  in  the  presence  of  one  or  more  of  the  following 
local  compUcations :  (a)  tuberculous  ulceration  of  the  bowel;  (b)  extensive  caseation 
of  the  mesenteric  glands  or  of  tuberculous  masses;  (c)  localized  suppuration  from 
infection  through  glands  or  the  intestine;  (d)  obstructive  symptoms  from  bands  or 
matting  of  the  intestine. 

6.  It  is  bad  in  the  presence  of:  (a)  the  rupture  of  a  suppurating  gland,  or  the 
perforation  of  an  intestinal  ulcer  into  the  peritoneal  cavity;  (b)  pulmonary  tubercu- 
losis:  (c)  tuberculous  meningitis;   (d)  general  miliary  tuberculosis. 

This  writer  further  concludes  that  the  prognosis  is  not  appreciably  affected  by 
simple  laparotomy. 

To  this  last  statement  of  Sutherland's  many  men  of  experience  will  take  excep- 
tion. It  has  been  generally  accepted  that  the  simple  opening  of  the  peritoneal  sac 
exerts  a  distinct  beneficial  influence  on  the  course  of  tuberculous  disease  involving  it. 
The  theories  to  explain  this  seeming  phenomenon  are  nearly  as  numerous  as  the 
writers  on  the  subject.  Although  it  cannot  be  denied  that  cures  have  followed  this 
measure,  yet  in  the  past  few  years  some  doubt  has  been  cast  on  its  efficacy  as  a 
remedial  measure.  Many  writers  still  contend  for  its  superiority  over  ordinary 
puncture  and  withdrawal  of  the  effusion. 

Regarded  in  the  light  of  an  exploratory  operation  with  the  possibility  of  finding 
and  removing  a  primary  focus  of  the  disease,  surgical  interference  is  most  certainly 
justified.  Otherwise  the  favorable  result  following  a  simple  laparotomy  cannot 
be  proved  to  be  entirely  due  to  the  operation  per  se,  as  there  is  always  the  possibility 
of  a  spontaneous  cure  by  Nature's  resources.  This  point  is  still  unsettled  and  must 
remain  so  for  the  present. 

In  view  of  the  fact  that  the  mortality  rate  from  laparotomy  in  cases  of  tubercu- 
losis of  the  peritoneum  is  so  low,  being  estimated  at  from  1  to  3  per  cent.,  and  in 
view  of  the  fact  that  nearly  all  cases  operated  on  are  temporarily  improved  (provided 
the  surgeon  does  not  try  to  do  too  much),  and  as  sepsis  is  not  likely  to  occur,  and 
particularly  as  there  is  a  chance  for  permanent  benefit,  it  seems  justifiable  to  operate 
early  in  all  operable  cases. 

The  Prognosis  as  Affected  by  Medicinal  Treatment. — Borchgrevink^  was 
one  of  the  first  to  insist  very  strongly  on  the  medical  treatment  of  tuberculosis  of  the 
peritoneum,  even  to  the  extent  of  condemning  all  surgical  procedures.  To  a  cer- 
tain degree,  he  has  had  many  followers,  and  Fenger,^  speaking  of  Borchgrevink's 
results,  says:    Borchgrevink  has  brought  the  subject  back  to  a  rational  basis  by 

'  Loc.  cit. 

^  Fenger,  Christian:  "Treatment  of  Tuberculosis  of  the  Peritoneum,"  Ann.  Surg.,  Phila., 
1901,  xxxiv,  771-786. 


632  TUBERCULOSIS    OF   THE    PERITOXEUM. 

most  scientific  and  careful  observation  of  two  almost  equal  series  of  cases  of  peri- 
toneal tuberculosis,  one  of  which  was  treated  by  laparotomy  and  the  other  without 
operation,  22  cases  in  the  first  group  and  18  in  the  second.  Of  the  22  cases  operated 
on,  11  patients  had  fever,  while  in  the  other  11  fever  was  not  present;  of  these  latter, 
10  hved  and  1  died;  of  the  11  with  fever,  8  died  and  only  3  were  cured.  In  17  cases 
conservative  treatment  was  employed;  of  these  14,  or  82.3  per  cent.,  recovered  and 
were  still  well,  or  at  least  chnically  cured,  after  two  or  three  years.  Of  the  three 
patients  who  died,  the  death  was  due  in  one  instance  to  tuberculous  peritonitis,  in  a 
second  to  intestinal  tuberculosis  after  six  months,  and  in  a  third  to  measles  after 
five  months.     His  conclusions  from  his  cases  are  the  f  oho  wing: 

1.  That  laparotomy  in  strong  patients,  in  whom  fever  is  absent  and  in  whom 
a  condition  of  good  nutrition  speaks  for  a  spontaneous  disappearance  of  the  tuber- 
culous process,  is  well  tolerated. 

2.  Laparotomy,  however,  in  patients  with  fever,  when  the  tuberculosis  has  a 
progressive  character,  must  diminish  what  slight  resistance  such  a  patient  has  re- 
maining. This  power  of  resistance  may  thus  ^ield,  and  death  follow,  or  it  may,  by 
concurrence  of  fortunate  circumstances,  rebound  and  the  patient  recover  in  spite 
of  the  operation. 

3.  That  form  of  peritoneal  tuberculosis  which  exists  without  fever,  or  vnth  only 
slight  fever,  runs  in  itself  a  favorable  course.  In  such  a  case  laparotomy  is  unne- 
cessarv.  In  progressive  tuberculosis  the  operation  is  dangerous  and  should  be 
abandoned. 

Borchgre\nnk  does  not  hesitate  to  add  that  even  the  "serous  tuberculous  peri- 
tonitis is  a  territory  which  surgery  must  hand  back  to  the  internal-medicine  clinic 
with  thanks  for  the  splendid  opportunity  which  a  misunderstanding  gave  to  the  pro- 
fession, by  means  of  laparotomy,  to  study  tuberculosis  in  one  of  the  large  cavities 
of  the  body. " 

On  the  whole,  statistics  as  to  the  value  of  medical  treatment  of  tuberculous  peri- 
tonitis are  not  very  complete,  and  it  is  difficult  to  say  just  what  propordon  of  cases 
end  in  spontaneous  recovery  because  of  the  uncertainty  of  diagnosis.  Shattuck^  re- 
ports on  98  cases  of  tuberculosis  of  the  peritoneum,  46  of  which  were  treated  without 
operation  with  apparent  recovery  in  39,  or  84.8  per  cent.,  while  of  the  52  cases  oper- 
ated upon  46,  or  88.4  per  cent.,  recovered.  Sutherland^  considers  the  prognosis 
from  the  result  of  41  cases  of  tuberculous  peritonitis  treated  at  Paddington  Green 
Children's  Hospital.  Twenty-seven  cases  were  treated  medicinally,  and  of  these 
22,  or  81.3  per  cent.,  recovered;  1  case  was  unreheved;  and  4,  or  15  per  cent.,  died. 
Of  the  14  cases  treated  by  laparotomy  7,  or  50  per  cent.,  recovered,  and  the  same 
number  of  cases  died. 

Hugentobler^  has  reported  67  cases  treated  internally  at  Eichhorst's  clinic,  with 
25  per  cent,  of  cures,  and  compares  his  results  with  those  of  Rose,  from  the  medical 
clinic  at  Strassburg,  numbering  71  cases.  Of  Rose's  cases,  51  had  been  under 
observation  for  a  long  enough  period  to  justify  definite  conclusions,  and  showed: 

1  Loc.  cit.  ^  Loc.  cit.  ^  Loc.  cit. 


TREATMENT. 


633 


Cured:   16  cases,  or  31  per  cent.;    not  cured:   1  case,  or  2  per  cent. ;  died:  34  cases, 
or  67  per  cent.     Hugentobler's  cases  are  arranged  as  follows : 


Age. 

Cured. 

Improved. 

Not  Cured. 

Died. 

Total. 

1-10 

1 

1 

3 

5 

11-20 

6 

2 

2 

4 

14 

21-30  

5 

7 

3 

5 

20 

31-40  

3 

1 

3 

8 

15 

41-50  

1 

1 

2 

4 

51-60  

1 

4 

5 

61-70  

1 

1 

2 

4 

Total ' 

17 

12 

10 

28 

67 

Schroeder^  reports  41.6  per  cent,  of  cures  in  a  total  of  24  cases  treated  in  the 
medical  clinic  at  Bonn,  and  Pic  (quoted  by  Giuldjides)  says  that  a  spontaneous  cure 
may  be  expected  in  20  per  cent,  in  adults  and  in  33  per  cent,  in  children,  while  con- 
tending that  laparotomy  cures  85  per  cent. 

By  comparing  the  statistical  results  of  cases  that  have  been  observed  for  a  suffi- 
cient time  after  treatment,  one  is  impressed  with  the  fact  that  the  figures  are  about 
the  same  in  those  treated  surgically  as  in  those  treated  by  medicinal  means,  and  one 
may  conclude  that  the  prognosis  for  recovery  is  good  in  from  one-fourth  to  one-third 
of  all  cases  of  tuberculosis  of  the  peritoneum. 


TREATMENT. 

Indications  and  Contraindications  for  Operation. — The  operative  treatment 
of  tuberculous  peritonitis  may  be  expected  to  yield  the  best  results  in  those  cases 
in  which  the  lesion  is  primary  within  the  abdomen,  particularly  if  the  primary  focus 
can  be  safely  extirpated.  As  it  is  generally  conceded  that  the  ascitic  form  is  most 
likely  to  be  primary  in  the  peritoneum,  this  would  be  the  most  favorable  type  on 
which  to  operate,  and  compiled  statistics  seem  to  bear  this  out.  It  is  a  fact,  says 
Duval,^  that  ascitic  tuberculous  peritonitis  furnishes  the  most  constant  and  perma- 
nent successful  operations;  sometimes  these  forms  may  be  cured  spontaneously, 
but  the  hope  of  cure  is  enhanced  if  the  operation  is  done  early. 

The  indications  for  operation  in  the  ulcerative  and  fibrous  forms  of  tuberculosis 
of  the  peritoneum  are  variously  discussed  by  different  operators.  Billings,  of 
Chicago,  feels  that  in  these  groups  the  surgeon  merely  writes  the  death  certificate, 
and  to  this  opinion  Halsted,  of  Baltimore,  and  Shattuck  are  also  inclined.  Other 
operators  feel  that  the  operative  chances  in  these  cases  are  still  encouraging,  as,  for 
example,  Aldibert,  who  reports  cures  in  the  ulcerative  caseous  form  of  the  disease 
in  59.1  per  cent,  of  primary  results,  permanent  cure  in  15  per  cent.,  while  the  mor- 
tality rate  was  40  per  cent. 

The  fibrous  form  of  tuberculous  peritonitis  may  demand  surgical  intervention 
because  of  such  complications  as  obstruction  of  the  bowel  by  adhesive  bands,  and 

'  Loc.  cit.  '  Loc.  cit. 


634  TUBERCULOSIS    OF   THE    PERITONEUM. 

because  of  the  involvement  of  nervous  and  vascular  trunks  causing  functional  dis- 
turbances and  pain.  Aside  from  these  indications,  however,  very  little  good  can  be 
accomphshed,  and  much  harm  may  be  done,  by  the  too  energetic  surgeon.  But 
it  must  be  remembered  that  these  cases  are  not  entirely  hopeless,  and  the  view  ob- 
tained at  operation  only  reveals  the  processes  adopted  by  Nature  in  her  endeavor 
to  limit  the  progress  of  the  disease,  and  it  is  probably  due  to  this  method  of  healing, 
and  not  to  operative  interference,  that  a  number  of  surgeons  have  reported  cures 
in  the  fibrous  type  of  tuberculous  peritonitis. 

Primary  tuberculosis  of  the  peritoneum  is  extremely  rare,  as  has  already  been 
mentioned.  In  not  a  few  instances,  however,  the  primary  focus  is  located  within 
the  abdominal  cavity,  and  this  fact  offers  the  best  indication  for  operative  measures, 
although  it  cannot  always  be  determined  before  operating.  Osier  has  estimated 
that  the  Fallopian  tubes  are  involved  in  from  30  to  40  per  cent,  of  cases.  Mayo  has 
reported  16  operations  for  tuberculous  peritonitis,  11  of  which  were  in  women,  with 
the  primary  focus  in  the  tubes  in  9,  in  the  appendix  in  1,  while  in  the  remaining  case 
the  focus  was  not  discovered ;  in  the  5  cases  in  men  the  focus  was  in  the  appendix 
and  cecum  in  3,  and  not  found  in  2.  Krencki^  reports  a  partial  or  complete  removal 
of  the  adnexa  in  9  of  his  cases,  with  7  recoveries.  Of  the  cases  taken  from  the  Utera- 
ture,  simple  laparotomy  gave  a  percentage  of  cures  in  66.17  per  cent.,  while  the 
removal  of  adnexa  with  laparotomy  showed  76.6  per  cent.,  or  an  increase  of  10  per 
cent.,  in  cures.  Schauta  claims  that  laparotomy  is  indicated  only  in  those  cases  of 
tuberculosis  of  the  peritoneum  in  which  no  tuberculous  lesions  exist  in  other  organs, 
especially  in  the  lungs. 

Vierordt  sees  no  contraindication  in  associated  mild  pulmonary  tuberculosis, 
while  Sick  goes  so  far  as  to  recommend  laparotomy  in  coexisting  pulmonary  and 
lymphatic  gland  tuberculosis.  Pribram  does  not  consider  a  slight  affection  of  the 
lung  a  contraindication.  Schwartz  contends  that  phthisis  does  not  contraindicate 
laparotomy  in  peritoneal  tuberculosis,  as  the  respiration  is  improved  by  the  lowering 
of  the  diaphragm.  From  this  it  would  seem  that  only  a  very  general  hopeless 
phthisis  would  be  a  contraindication  to  operation.  The  ad  visibility  of  operating 
in  the  presence  of  tuberculous  enteritis  is  viewed  differently  by  writers.  Vierordt 
and  Pic  do  not  operate  in  this  condition,  while  Israel,  on  the  other  hand,  says  that 
a  simple  laparotomy  in  this  class  may  bring  about  a  permanent  cure.  In  general, 
it  should  be  said  that  every  means  should  be  employed  to  choose  the  proper  time 
for  operating,  and,  as  a  rule,  only  afebrile  cases  should  be  chosen. 

Technic  of  Operations. — The  simplest  surgical  procedure  that  has  been 
adopted  in  the  handling  of  tuberculous  peritonitis  consists  of  opening  the  abdomen, 
removing  any  effusion  that  may  be  present,  and  closing  the  incision  without  drain- 
age. In  many  instances,  as  in  the  unique  experience  of  Sir  Spencer  Wells,  this 
measure  has  been  followed  by  permanent  recovery.  Of  late,  however,  many  oper- 
ators have  become  skeptical  as  to  the  value  of  such  a  simple  procedure,  but  many 
still  speak  for  its  advantages  over  treatment  by  paracentesis.     Trans-abdominal 

^  Loc.  cit. 


TREATMENT.  635 

laparotomy  has  always  been  the  prevalent  operation,  although  a  few  men,  Con- 
damin  and  others,  have  used  the  vaginal  route  in  suitable  cases. 

This  simple  operation  is  modified  in  various  ways.  Most  authorities  advise 
against  drainage,  although  it  has  been  shown  that  the  wound  usually  heals  well  and 
is  rarely  attacked  by  tuberculous  processes.  Others  combine  laparotomy  with 
vaginal  puncture.  Many  operators  wash  out  the  abdominal  cavity  with  salt  solu- 
tion, or  with  mild  antiseptic  solutions  of  bichlorid,  iodin,  etc.  Many  dust  iodoform 
Hghtly  over  the  peritoneum.  Strong  antiseptics  only  do  harm  and  should  be  con- 
demned. The  opinion  of  Lawson  Tait  is  that  drainage,  irrigation,  and  medication 
of  the  abdominal  cavity  in  these  cases  are  not  only  useless  but  positively  undesirable, 
and  Treves  has  shown  from  the  analysis  of  300  cases  that  the  best  possible  results 
are  obtained  when  the  abdominal  cavity  is  neither  flushed  out  nor  drainage  em- 
ployed. 

In  the  ulcerous  form  incision  is  made  at  the  point  where  fluctuation  is  best  ob- 
tained. Great  care  is  to  be  exercised  on  account  of  the  frequent  adhesions  of  the 
parietal  peritoneum  to  the  omentum  or  intestines.  The  pus  should  be  removed, 
but  no  attempt  should  be  made  to  remove  the  false  membranes  which  adhere  to  the 
peritoneum,  nor  to  liberate  the  coils  of  intestines  which  may  be  agglutinated,  as 
there  is  considerable  risk  of  rupturing  the  coats  of  the  intestines,  which  are  extremely 
friable.  Caseous  glands  may  be  removed  and  also  any  large  caseous  masses,  pro- 
vided it  is  possible  to  cut  into  healthy  tissue.  Special  attention  should  be  given  to 
the  condition  of  the  appendix  and  tubes,  as  they  can  usually  be  readily  removed  if 
diseased. 

In  the  fibrous  form  of  tuberculosis  of  the  peritoneum,  the  less  done  the  better, 
and  the  only  excuse  to  continue  the  operation  when  this  form  of  peritonitis  is  found 
is  for  the  purpose  of  relieving  intestinal  obstruction. 

A  review  of  the  literature  on  the  subject  of  the  surgical  treatment  of  tuberculous 
peritonitis  shows,  on  the  whole,  a  rather  uniform  mode  of  procedure,  with  here  and 
there  an  individual  variation.  Shattuck^  states  that  the  procedure  at  the  Massa- 
chusetts General  Hospital  consists  in  opening  the  abdomen,  sponging  and  washing 
out  the  fluid  with  salt  solution  or  plain  water,  and  removing  large  masses  of  tuber- 
culous tissue  when  found.  The  abdomen  was  closed  in  32  cases,  drained  in  20. 
Forty-six  cures  are  reported  in  these  52  cases. 

Mayo^  proceeded  as  follows:  If  the  patient  is  a  woman,  the  fluid  is  evacuated, 
the  patient  is  then  placed  in  the  Trendelenburg  position,  and  the  general  abdominal 
cavity  is  packed  off  in  the  usual  manner.  The  pelvic  organs,  appendix,  and  cecum 
are  now  examined.  If  the  Fallopian  tubes,  appendix,  or  cecum  are  diseased  they 
are  removed.  The  stumps  and  walls  of  tuberculous  abscess  cavities  are  dried  and 
rubbed  with  sterile  gauze  and  the  abdomen  is  closed  without  drainage.  Drainage 
sometimes  leads  to  secondary  mixed  infection,  with  resulting  fistul?e,  which  have  a 

'  Loc.  cit. 

^Mayo,  W.  J.:  "Surgical  Tuberculosis  in  the  Abdominal  Cavity  with  Special  Reference  to 
Tuberculous  Peritonitis,"  Jour.  Am.  Med.  Assoc,  Chicago,  1905,  xliv,  1157-1160. 


636  TUBERCULOSIS    OF   THE   PERITONEUM, 

decided  tendency  to  become  fecal.  If  the  patient  is  a  man,  the  incision  is  placed 
to  the  right  of  the  median  hne,  over  the  appendix.  The  fluid  is  evacuated,  the 
appendix  and  cecum  are  examined,  and,  if  conditions  warrant,  a  radical  operation 
is  performed.  If  there  are  masses  of  fibrous  tissue  about  the  cecum,  it  is  removed 
and  the  ends  of  the  ileum  and  colon  are  closed  by  suture  and  a  lateral  ileocolostomy 
is  performed.  In  some  cases  greatly  enlarged  tuberculous  lymph-glands  exist  in 
the  mesentery.     As  many  of  these  as  possible  are  removed. 

Neff^  states  that  a  simple  laparotomy,  made  rapidly  but  with  great  care,  on 
account  of  the  liability  of  intestinal  and  other  adhesions,  without  irrigation  or  medi- 
cation of  the  abdominal  cavity,  promises  the  best  result.  It  may  be  necessary  to 
drain  in  some  cases.  Hydrops  should  be  evacuated  when  present.  When  there 
is  an  encysted  mass,  the  adhesions  should  be  separated  and  the  cavity  sponged  out, 
provided  it  will  not  cause  too  much  tearing  and  bleeding.  He  calls  attention  to  the 
fact  that  the  mortality  is  less  than  3  per  cent.;  that  marked  improvement  occurs 
in  about  80  per  cent,  and  that  a  permanent  cure  is  effected  in  about  50  per  cent,  of 
all  cases  operated  on. 

Ochsner^  states  that  a  review  of  the  literature  has  convinced  him  that  surgeons 
who  insist  upon  thoroughness  in  these  operations  had  most  unsatisfactory  results. 
In  his  experience  recovery  has  been  somewhat  more  rapid  and  permanent  in  cases 
in  which  a  glass  drainage-tube,  covered  with  iodoform  gauze,  was  inserted  into  the 
cul-de-sac  of  Douglas  and  withdrawn  as  soon  as  it  ceased  to  drain.  He  warns 
against  intra-abdominal  manipulations,  especially  of  the  infected  intestines,  but 
believes  that  the  diseased  pelvic  organs — uterus,  ovaries,  and  tubes — can  be  handled 
with  less  harm. 

Giuldjides^  operates  as  follows:  An  incision  is  made  in  most  instances  in  the 
median  line  below  the  umbilicus.  It  may  be  made  parallel  with  the  median  line 
through  the  left  rectus  muscle  fv.  Winckel).  Only  a  few  authors  recommend  coelio- 
tomia  vaginalis  (Condamin,  Lohlein).  The  fluid  exudate  is  carefully  removed 
with  sponges.  Irrigations  with  antiseptic  solutions  are  not  used,  except  in  the  sup- 
purative form  of  tuberculous  peritonitis,  in  which  case  a  mild  agent  is  used,  as 
boracic  or  salicylic  acid,  weak  carbolic  acid,  thymol,  weak  zinc  chlorid  solution, 
iodoform,  or  only  sterile  physiologic  salt  solution.  The  resection  of  separate  organs 
is  recommended  only  in  circumscribed,  diseased,  easily  extirpated  parts.  Mar- 
garucci  recommends  the  loosening  of  adhesions  only  when  such  a  procedure  is 
necessary,  as  in  occlusion  of  the  intestine,  pain,  etc.  Others  advise  the  excision  of 
the  primary  lesion  wherever  possible  (Lohlien,  Vierordt,  Fehling,  de  Quervain). 
Drainage  is  unnecessary,  as  a  rule,  and  is  best  omitted,  as  it  may  lead  to  stubborn 
fistulse. 

Bottomley'*  finds  that  incision  into  the  peritoneal  cavity,  evacuation  of  the  fluid, 

'  Neff,  Wallace:  "Resume  of  the  Latest  Literature  on  Tuberculosis  of  the  Peritoneum,"  Tr. 
South.  Surg,  and  Gynec.  Assoc,  Phila.,  1901,  xiii,  377-386. 

^  Ochsner,  A.  J.:  "The  Toilet  of  the  Peritoneum  in  Tuberculous  Peritonitis,"  Ann.  Gynec. 
and  Pediat.,  Boston,  1903,  xvi,  507-509. 

^  Loc.  cit.  ''  Loc.  cit. 


TREATMENT.  637 

and  closure  of  the  wound,  give  as  good  results  as  the  more  extensive  procedures. 
He  does  not  believe  that  the  tubes  and  ovaries  should  be  removed  in  every  case  in 
which  they  are  affected,  and  he  believer  that  the  diseased  process  in  these  organs, 
as  well  as  in  the  indurated  omental  masses,  may  resolve  spontaneously  when  left 
in  situ  after  the  more  simple  operation. 

Medicinal  Treatment. — The  hygienic  conditions  surrounding  the  patient 
with  tuberculosis  of  the  peritoneum  should  be  of  the  very  best,  and  this  applies, 
of  course,  to  those  treated  surgically  as  well  as  to  those  not  submitted  to  operation. 
The  rigid  enforcement  of  the  principles  of  treating  tuberculosis  in  general  applies 
equally  to  this  disease  of  the  peritoneal  membranes.  The  sine  qua  non  is  the  com- 
bination of  good  food  and  fresh  air. 

Teleky,^  writing  in  1899,  summed  up  the  whole  question  as  to  the  value  of  the 
internal  or  non-operative  handling  of  tuberculous  peritonitis.  There  is  no  specific 
with  which  to  treat  this  affection  as  yet,  although  considerable  importance  may 
attach  to  the  very  recent  work  in  the  opsonic  factors.  The  local  remedies  consist 
of  hot  applications  and  counter-irritation.  For  the  intestinal  troubles,  pain,  etc., 
enemata  are  given  and  small  doses  of  opium  are  indicated.  Byford^  feels  that  there 
is  some  value  in  the  use  of  intestinal  antiseptics.  The  place  of  tonics,  as  the  syrup 
of  the  iodid  of  iron,  cod-liver  oil,  arsenic,  etc.,  is  recognized.  The  three  essentials, 
however,  are  absolute  rest  in  bed,  abundant  fresh  air,  and  hyperalimentation. 
Spontaneous  healing  has  been  shown  to  take  place  in  a  sufficient  number  of  in- 
stances to  induce  us  to  apply  in  every  case  of  tuberculous  peritonitis,  whether  on 
the  medical  or  surgical  side,  the  ideal  conditions  to  favor  such  an  outcome.  As 
regards  the  use  of  drugs,  the  most  important  item  is  to  see  that  nothing  is  pre- 
scribed that  can  in  any  way  upset  the  stomach,  for  as  long  as  the  appetite  and  diges- 
tion remain  unimpaired,  so  does  the  prognosis  hold  good. 

For  additional  information  the  reader  is  referred  to  Chapter  XVI,  page  623, 
Vol.  I,  and  to  Chapter  XXV,  page  552,  Vol.  II. 

The  treatment  of  tuberculosis  by  means  of  specific  products  of  the  tubercle 
bacillus  has  been  a  subject  of  much  investigation  since  1890,  when  Koch  first  intro- 
duced tuberculin  as  a  curative  agent.  The  results  in  general  have  been  disappoint- 
ing, although  of  late  interest  has  been  revived  in  all  forms  of  serum-therapy  through 
the  impetus  given  by  Wright  and  Douglas  in  their  investigations  concerning  the 
opsonic  factors  in  the  blood-serum. 

Many  physicians  have  continued  to  make  use  of  tuberculin  preparations  since 
the  early  90's  in  conjunction  with  the  dietetic,  hygienic,  climatic,  and  proper  symp- 
tomatic treatment  of  tuberculosis.  Among  these  is  von  Ruck,  in  Asheville,  who 
feels  that  they  have  added  greatly  to  his  results  both  in  numbers  improved  and 
apparently  cured,  as  well  as  to  the  permanence  of  results  after  discharge.     In  a 

^  Loc.  cit. 

^  Byford,  Henry  T.:  "The  Intestinal  Treatment  of  Tuberculous  Peritonitis,"  Ann.  Surg., 
Phila.,  1899,  xxx,  253-259. 


638  TUBERCULOSIS    OF   THE    PERITONEUM. 

recent  report^  von  Ruck  gives  59.6  per  cent,  of  apparent  recoveries  in  a  series  of 
two  hundred  and  sixty-one  cases  of  pulmonary  tuberculosis  treated  by  the  combined 
method,  and  quotes  extensively  from  the  literature  as  to  the  good  results  obtained 
from  the  employment  of  tuberculin  as  a  curative  agent.  In  this  same  report  he  cites 
a  very  interesting  case  of  peritoneal  tuberculosis  in  which  a  test  dose  of  0.5  mg.  of 
tubercuhn  was  administered,  followed  by  marked  general  and  local  symptoms,  and 
a  speedy  and  permanent  recovery.  Yon  Ruck"  has  treated,  in  all,  four  cases  of 
tuberculous  peritonitis  by  specific  treatment,  with  three  recoveries  dating  back  two, 
three,  and  six  years,  respectively.  The  fourth  case  was  not  influenced  by  the  treat- 
ment, as  the  patient  was  in  an  advanced  stage  of  phthisis,  and  the  injections  were 
given  but  a  short  time.  In  all  of  his  cases  local  reaction  to  the  tubercle  bacillus 
extract  was  manifest  following  minute  doses,  and  consisted  of  general  diffuse  tender- 
ness and  local  pain  in  the  abdomen.  He  is  inclined  to  believe  that  the  explanation 
for  the  effect  of  the  tuberculin  is  similar  to  that  given  for  the  action  of  laparotomy  in 
tuberculous  peritonitis  by  Nassauer,  who,  on  reopening  the  abdomen  three  hours 
after  operation,  observed  a  hyperemia  of  a  degree  which  he  says  cannot  be  appre- 
ciated unless  actually  seen. 

Recoveries  from  tuberculous  peritonitis  following  the  therapeutic  use  of  tuber- 
culin have  been  reported  by  Riegel;^  Kiimmel,*  in  a  case  in  which  two  previous 
laparotomies  had  failed;  Comes,^  cure  confirmed  by  autopsy;  Leser;*^  Conitzer,^ 
three  cases  in  children;  Rumpf  ;*  ]McCall;''  Aufrecht;^"  and  Gray." 

From  a  conflicting  mass  of  case  reports  it  is  most  difficult  to  draw  distinct  con- 
clusions as  to  the  relative  values  of  the  different  methods  proposed  for  the  cure  of 
tuberculosis  of  the  peritoneum.  In  general,  it  may  be  said  that  in  an  affection  of 
this  kind  one's  first  efforts  should  be  directed  toward  treating  the  patient,  while  the 
second  consideration  has  to  do  with  the  most  approved  method  of  handling  the  local 
process.  AYhether  this  is  to  be  done  surgically,  symptomatically,  or  specifically  will 
depend,  for  the  present,  very  largely  on  the  attitude  of  the  physician  in  charge. 

1  Von  Ruck,  Karl  and  Silvio:  "A  Clinical  Study  of  Two  Hundred  and  Sixty-one  Cases  of  Pul- 
monary Tuberculosis,"  etc.     Asheville,  N.  C,  1905,  51. 

^  Personal  communication. 

^  Riegel,  F.:  "Bericht  ueber  die  mit  dem  Koch'schen  Mittel  gemachten  Erfahrungen," 
Deutsche  med.  Wochenschr. ,  Leipz.  u.  Berl.,  1891,  xvii,  409-412. 

^Kummel:    "Beobachtungen  mit  dem  Koch'schen  Heilmittel,"  Ibid.,  1891,  xvii,  691-692. 

^  Comes:   Inaug.  Diss.,  Bonn,  1891. 

'  Leser,  E:  "Ueber  die  Erfolge  der  Tuberculinbehandlung  bei  Chirurgischer  Tuberculose  der 
Kinder,"  Miinch.  med.  Wochenschr.,  Dec,  1891,  xxxviii.  835,  p.  834. 

'Conitzer:  "Zur  Laparotomie  der  Bauchfelltuberkulose  der  Kinder,"  Deutsche  med.  Woch- 
enschr., Leipz.  u.  Berl.,  xix,  1283. 

^Rumpf:  "Zwei  Falle  von  Peritonitis  tuberculosa,"  Deutsche  med.  Wochenschr.,  Leipz.  u. 
Berl.,  1896,  xxii,  Vereins-Beilage,  51-52. 

»M'Call,  Anderson:  "A  Case  of  Tubercular  Peritonitis  treated  with  Tuberculin,"  Scott. 
Med.  and  Surg.  Jour.,  Edinb.,  1904,  xv,  520. 

'°  Aufrecht:  "Erfolgreiche  Anwendung  des  Tuberculins  bei  fiebernden  Phthisikern,"  Deutsche 
med.  Wochenschr.,  Leipz.  u.  Berl.,  1905,  xxxi,  1741. 

"Gray,  H.  M.  W.:    "Vaccine  Treatment  in  Surgery,"  Lancet,  Lond.,  1906,  i,  1099-1103. 


CHAPTER  XXXIX. 

PENETRATING  WOUNDS  OF  THE  ABDOMEN. 
By  Floyd  W.  McRae,  M.D. 

Historical. — The  history  of  the  advance  made  in  the  treatment  of  penetrating 
wounds  of  the  abdomen  is  practically  the  history  of  abdominal  surgery.  Pene- 
trating wounds  have  always  been  regarded  as  of  great  import,  and,  as  in  the  case 
of  other  accidents  attended  with  a  high  mortality,  the  best  method  of  treatment 
has  been  and  is  now  a  subject  of  discussion.  Among  the  older  medical  writers 
there  were  two  schools,  at  variance  with  one  another  regarding  the  proper  treat- 
ment of  penetrating  wounds  of  the  abdomen.  The  one  advocated  palliative 
treatment,  in  that  the  parietal  wound  should  be  kept  open,  various  applications 
made,  and  large  doses  of  opium  administered;  the  other,  realizing  the  frightful  mor- 
tality attending  such  a  course,  advocated  bolder  measures — enterorrhaphy,  cleans- 
ing of  the  peritoneal  ca\aty,  etc.  While  the  advocates  of  the  latter  practice  were 
quite  few,  it  is  interesting  to  review  the  opinions  of  some  of  them. 

In  1606  Fallopius^  favored  enlargement  of  the  external  wound  in  order  to  expose 
intestinal  lesions  and  to  practise  enterorrhaphy. 

In  1759  Heister  stated  that  he  saw  no  objection  to  the  enlargement  of  the 
parietal  wound,  since  upon  the  neglect  of  it  certain  death  would  follow.  It  appears, 
however,  that  little  attention  was  given  this  teaching  until  1836,  when  Baudens^ 
reported  two  cases  operated  on  in  1831.  Of  these,  one  recovered.  He  advised 
enlargement  of  the  parietal  wound,  exploration  of  the  peritoneal  cavity,  repair  of 
lesions,  and  the  execution  of  suitable  measures,  e.  g.,  enterorrhaphy. 

Pirogoff^  in  1849  operated  for  two  shot  perforations  of  the  ileum.  He  considers 
this  procedure  the  "only  possible  resource  in  such  injuries."  Lohmeyer,^  incase 
peritonitis  was  set  up  by  the  escape  of  the  intestinal  contents,  advised  probing  of 
the  wound,  closure  of  the  perforation,  removal  of  the  fecal  material,  and  approxi- 
mation of  the  abdominal  wound. 

Legouest,^  in  the  year  1863,  wrote:  "In  lesions  of  the  intestine  by  cutting  weapons 
attended  by  the  extravasation  of  solid  or  liquid  contents,  and  in  shot  wounds,  it  is 
then  proper  to  enlarge  the  external  wound  with  the  bistoury,  to  draw  the  gut  out- 
ward and  to  close  the  solution  of  continuity  by  suture." 

^  Quoted  by  Otis  in  "Medical  and  Surgical  History  of  the  War  of  the  RebelHon,"  Part  Second, 
Surgical  Vol.,  page  63,  note  2. 

^  Laurentius:  "A  System  of  Surgery,"  7th  edition,  chap,  vii,  p.  75. 
^Baudens:  "Clinique  des  plaies  d'armes  a  feu,"  18.36,  p.  322. 

^Pirogoff,  Nikolas:  "Rap.  med.  d'un  voyag.  au  Cauc,"  1849;  "  Grundziige,"  u.  s.  w.,  1864,  578. 
^Lohmeyer:  "Die  Shusswiinden  und  ihre  Behandlung,"  Gottingen,  1859,  S.  161. 
*Legouest,  V.  A.  L.:    "Traite  de  Chirurgie  d'Armee,"  vol.  x,  p.  385. 

639 


640  PENETRATING   WOUNDS    OF   THE    ABDOMEN. 

Demme^  said  that  on  account  of  the  element  of  uncertainty  in  penetrating 
wounds,  he  did  not  advise  the  further  opening  of  the  wound  and  a  search  for  the 
wounded  intestine.  When  the  conditions  were  exceptionally  clear  he  thought  the 
procedure  rational. 

Hamilton,"  in  1865,  said:  "Be  assured  the  patient  will  have  a  better  chance  for 
life  if  we  let  him  entirely  alone — and  it  surprises  us  that  any  good  surgeon  should 
think  otherwise." 

Gross,^  in  1872,  said  that  the  enlargement  of  the  parietal  wound  and  the  seeking 
for  wounded  intestine  was  not  the  proper  thing  in  gunshot  wounds;  he  restricted 
such  procedures  to  stab  wounds. 

Erichsen,*  in  1873,  said  that  operative  measures  were  not  called  for  unless  the 
wounded  gut  protruded  or  fecal  material  escaped  into  the  peritoneal  cavity. 

Billings,  McGuire,  Hewit,  and  Lincoln'  advised  opening  the  abdomen  and 
making  a  careful  search  for  the  wounded  intestine. 

The  real  advocate,  however,  of  exploratory  laparotomy  for  penetrating  abdo- 
minal wounds,  and  the  one  who  first  insisted  strenuously  on  its  employment  and  its 
necessity  in  these  cases,  was  J.  Marion  Sims.®  He  said :  "Given  a  case  of  penetrating 
abdominal  wound,  one  should  open  the  abdomen  promptly,  clean  out  the  peritoneal 
cavity,  search  for  the  wounded  intestine,  pare  its  edges  and  bring  them  together 
with  sutures;  and  then  treat  the  case  as  we  now  treat  other  cases  involving  the  peri- 
toneum. Rest  assured  that  the  day  will  soon  come  when  an  accurate  diagnosis 
in  such  cases,  followed  by  prompt  action,  will  save  life  that  otherwise  must  quickly 
ebb  away." 

Kinloch,^  in  1882,  was  the  first  to  publish  a  distinctly  exploratory  laparotomy 
for  gunshot  wound.  In  1883  Kocher*  had  a  successful  case.  In  1885  BulP  reported 
a  successful  case  of  laparotomy  for  gunshot  wound  before  the  New  York  Medical 
Society.  From  this  time  on,  it  is  interesting  to  note  that  the  number  of  laparotomies 
has  steadily  increased,  and  Morton^"  in  1890  was  able  to  collect  ninety-four  cases 
operated  on  by  sixty-eight  American  surgeons. 

Diagnosis. — The  diagnosis  of  penetration  of  the  abdomen,  in  civil  practice, 
cannot  be  made  with  even  approximate  accuracy  without  laying  open  the  wound. 
Attempts  to  follow  wounds  with  the  finger  or  the  probe  frequently  eventuate  in 

'  Demme,  Herrman:  "Militar-chirurgische  Studien  in  dem  italienischen  Lazarethen,"  1861. 

^Hamilton,  F.  H.:  "A  Practical  Treatise  on  Military  Surgery  and  Hygiene,"  p.  354. 

^  Gross,  Samuel  D.:  "A  System  of  Surgery,"  ii,  614. 

^  Erichsen,  J.:  "The  Science  and  Art  of  Surgery." 

5  "Med.  and  Surg.  Hist.  War  Rebellion,"  Part  Second,  Surgical  Vol.,  p.  126. 

°  Sims,  J.  Marion:  "Remarks  on  the  ~ Treatment  of  Gunshot-wounds  of  the  Abdomen  in 
Relation  to  Modern  Peritoneal  Surgery,"  Brit.  Med.  Jour.,  1881,  ii,   925. 

'Kinloch,  R.  A.:  "Gunshot  Wound  of  Abdomen,  Treated  by  Opening  Cavity  and  Suturing 
Intestine,"  North  Carolina  Med.  Jour.,  1882,  July,  page  1. 

^Kocher  Theodor:  "Gunshot  Wound  of  the  Stomach:  Successful  Laparotomy,"  Brit.  Med. 
Jour.,  1884,  ii,  78. 

*Bull,  W.  T. :  "A  Case  of  Gunshot  Wound  of  Intestine  Treated  Successfully  by  Laparotomy 
with  Suture  of  the  Intestines,"  New  York  Med.  Jour.,  1885,  xh,  p.  184. 

"Morton,  T.  S.  K.:  "Abdominal  Section  for  Traumatism,with  Tables  of  Cases,"  Jour.  Amer. 
Med.  Assoc,  1890,  i. 


TREATMENT.  641 

failure — neither  confirming  nor  disproving  penetration.  These  are  dangerous  ex- 
pedients— universally  condemned  by  the  best  authorities. 

According  to  the  most  reliable  statistics  recorded,  in  only  10  per  cent,  of  the  cases 
of  penetrating  abdominal  wounds  do  the  hollow  and  solid  viscera  escape  serious 
injury.  There  is  but  one  positive  sign  of  intestinal  perforation — seen  exception- 
ally— the  escape  of  gas  or  feces  externally.  Shock  is  a  very  variable  symptom, 
marked  in  nervous  individuals,  often  practically  absent  in  men  of  great  fortitude 
in  spite  of  grave  lesions.  AVhen  pronounced  and  persistent,  it  is  strong  presumptive 
evidence  of  free  bleeding.  Nausea,  vomiting,  and  muscular  tension  are  signs  of 
value.  The  vomitus  should  be  examined  for  blood.  Blood  in  the  stools  is  rarely 
observed  early  enough  to  be  of  diagnostic  value  as  indicating  perforation  of  an 
intestine.  The  Senn  hydrogen  gas  test  has  proved  unreliable  and  dangerous;  it  is 
conclusive,  not  exclusive. 

Treatment. — In  civil  Ufe,  with  fair  hospital  facilities,  aseptic  technic,  and  a 
competent  surgeon  available,  almost  every  penetrating  wound  of  the  abdomen  that 
does  not  prove  immediately  fatal  on  account  of  shock  and  hemorrhage  should  be 
dealt  with  by  means  of  prompt  operation.  When  everything  is  ready,  the  prepara- 
tion of  the  patient  should  be  made  on  the  operating  table  during  the  administration 
of  the  anesthetic;  the  stomach  should  be  washed  out,  and  the  field  of  operation 
thoroughly  prepared.  If  there  is  any  doubt  that  the  wound  is  penetrating,  it  should 
be  traced.  By  tracing  is  meant  laying  open  the  wound  of  entrance,  the  wound  of 
exit,  and  the  intervening  tract  of  the  bullet.  Any  one,  or  all  three,  may  be  neces- 
sary to  prove  or  disprove  penetration  of  the  peritoneal  cavity  beyond  doubt. 

If  the  wound  is  penetrating,  the  operation  should  be  so  extended  as  to  constitute 
an  exploratory  celiotomy;  and  if  visceral  damage  is  found,  immediate  repair  should 
be  made.  Unless  very  unsuitably  located,  the  wound  of  entrance  should  be 
enlarged  enough  for  a  thorough  exploration.  When  this  is  not  advisable,  a  median 
incision,  either  above  or  below  the  umbilicus,  should  be  made.  The  location  of 
the  incision  should  be  determined  by  the  history  of  the  case,  the  position  of  the  patient 
when  hit  by  the  bullet,  the  angle  from  which  it  w^as  fired,  and  its  probable  course. 

On  opening  the  abdomen  the  escape  of  any  gas  or  feces  should  be  noted  and 
immediate  search  be  made  for  the  bleeding  vessel  or  vessels,  if  there  is  profuse  hemor- 
rhage. Free  bleeding  should  be  arrested  at  once,  and  if  essential  to  its  accompKsh- 
ment  the  incision  should  be  enlarged  and  the  patient  partially  or  completely  even- 
trated.  These  extreme  measures  should  be  avoided  if  possible.  Long  incisions, 
evisceration,  undue  exposure  of  intestines,  and  rough  handling  greatly  increase  the 
operative  mortality. 

The  first  part  of  the  intestine  encountered  should  be  brought  out  of  the  wound 
and  a  tape  or  a  strip  of  gauze  thrown  round  it  by  pushing  one  end  through  the 
mesentery,  between  vessels,  with  a  hemostat.  The  ends  of  the  tape  or  gauze  are 
caught  and  held  by  forceps;  and  a  cross-nick  is  made  either  above  or  below  to  give 
a  definite  point  of  departure.  This  is  a  little  procedure  of  great  practical  value, 
requiring  only  a  few  seconds  of  time  for  its  accomplishment.     To  look  for  the  ileo- 

VOL.  TI 41 


642  PENETRATING   WOUNDS    OF   THE   ABDOMEN. 

cecal  junction  or  some  other  readily  recognizable  portion  of  the  intestinal  tract  is  a 
waste  of  time,  and  the  additional  handling  tends  to  spread  infection  in  the  presence 
of  perforation  with  leakage.  The  whole  intestinal  tract  should  be  rapidly  examined, 
first  above  and  next  below  the  gauze.  SKts  in  the  mesentery  should  be  repaired, 
bleeding  arrested,  and  intestinal  perforations  closed  as  found.  When  it  can  be 
done  without  too  much  contracture  of  the  lumen  of  the  gut,  perforations  on 
the  convex  surface  should  be  closed  in  its  longitudinal  axis.  Perforations 
near  the  mesenteric  border  usually  can  be  closed  best  transversely.  Less  obstruc- 
tion is  offered  to  the  fecal  flow  by  a  longitudinal  seam  than  by  a  transverse  one,  and 
the  dangers  from  leakage  and  obstruction  are  consequently  diminished.  Care 
should  be  taken  to  see  that  the  mesenteric  vessels  supplying  the  intestine  are  not 
interfered  with.  When  the  margins  of  the  perforation  are  ragged  and  contused,, 
they  should  be  trimmed  off.  When  the  wound  is  small  and  clean-cut,  interrupted 
Lembert  sutures  are  all  that  is  necessary.  When  the  perforation  is  long  and  ragged, 
a  few  interrupted  Czerny  sutures  should  be  inserted;  over  these  Lembert  sutures  of 
celluloid  linen  (Pagenstecher)  or  silk  should  be  placed  to  close  the  perforation  accu- 
rately— care  being  taken  not  to  infold  too  much  tissue.  The  intesdne  in  gunshot 
perforation  is  often  in  a  state  of  spasmodic  contraction.  I  have  found  this  condition 
present  in  some  part  of  the  alimentary  canal  in  almost  every  case  of  gunshot 
wound  that  has  come  under  my  observation.  This  contraction,  reducing  the  gut 
much  below  its  normal  caliber,  enhances  the  danger  of  infolding  too  much  tissue^ 
the  bite  of  the  suture  being  six  to  eight  times  deeper  than  it  would  have  been  had 
the  gut  retained  its  normal  degree  of  distention  and  relaxation. 

When  there  is  considerable  separation  of  the  gut  from  its  mesentery,  resection 
and  end-to-end  anastomosis  should  be  done.  It  is  frequently  a  question  of  judg- 
ment as  to  whether  a  large  number  of  perforations,  close  together,  should  be  sutured 
separately,  or  a  resection  of  that  part  of  the  intestine  be  resorted  to.  The  latter 
is  generally  considered  to  be  the  better  procedure,  taking  less  time  and  diminishing 
the  danger  of  obstruction.  When  a  resection  is  done  the  intestine  should  be  cut 
across  obhquely,  so  as  to  be  sure  that  the  mesenteric  border  is  a  little  longer  than 
the  convex  border.  The  anastomosis  can  best  be  accomplished  by  continuous 
Czerny-Lembert  sutures  of  Pagenstecher  or  silk,  the  mesenteric  borders  first  being 
approximated  accurately  by  the  Ivlaunsell  mattress-mesenteric  suture.  The  approx- 
imation of  the  cut  ends  is  facilitated  by  interrupted  sutures  dividing  the  intestines 
into  thirds,  as  suggested  by  Connell.  Where  haste  is  essential,  the  ]Murphy  button 
may  be  used  instead  of  sutures.  For  a  detailed  description  of  intestinal  repair, 
anastomoses,  etc.,  the  reader  is  referred  to  Chapter  XXXIV,  Vol.  II. 

The  intestine  should  be  cleansed  by  moist  sponging  as  the  operation  proceeds. 
If  it  is  necessary  to  keep  any  considerable  part  of  the  gut  outside  of  the  abdominal 
cavity  for  a  length  of  time,  it  should  be  covered  by  pads  or  towels  wrung  out  of  warm 
normal  salt  solution,  and  it  should  be  kept  moist  and  warm  by  frequently  wetting 
the  gauze  with  warm  salt  solution.  This  should  be  done  by  the  assistant  or  the 
nurse.      Under  ordinary  conditions,  only  a  small  part  of  the  intestine  need  be 


TREATMENT.  643 

withdrawn  from  the  abdomen  at  a  time;  as  the  surgeon  draws  out  and  traces  the 
intestine  his  assistant  follows  after  and  replaces  it  in  the  abdominal  cavity.  After 
examining  from  the  point  of  departure  upward  to  the  end  of  the  gut  above  or  below 
as  the  case  may  be,  the  part  of  the  intestine  on  the  other  side  of  the  gauze  is  drawn 
out  by  the  strip  of  gauze  around  it  and  followed  in  the  same  way  as  above  described, 
dealing  with  each  injury  seriatim.  The  strip  of  gauze  around  the  intestine  is  next 
removed  and  the  wound  in  the  mesentery  closed. 

Careful  handling  of  the  intestine,  without  undue  exposure,  is  essential  in  order 
to  secure  good  results.  Evisceration,  rough  handling,  and  a  long  exposure  of  the 
intestine  have  turned  the  scales  in  many  of  these  abdominal  injuries,  and  led  to 
a  fatal  result. 

Many  of  the  deaths  occurring  seven  to  ten  days  after  operations  done  for  pene- 
trating wounds  of  the  abdomen  are  due  to  perforation  caused  by  sloughing  of  the 
intestine,  owing  to  separation  from  its  mesentery.  It  must  ever  be  borne  in  mind 
that  a  gut  separated  from  its  mesenteric  blood-supply  cannot  live. 

Note  should  always  be  taken  of  the  presence  of  urine  in  the  peritoneal  cavity, 
and  the  bladder  should  be  examined  for  injury.  If  the  bladder  has  been  perfor- 
ated, it  should  be  sutured  accurately  by  interrupted  sutures  of  catgut  which  em- 
bra;ce  all  the  coats  down  to  .the  mucous  membrane.  If  the  suture  line  cannot 
be  tested  by  distending  the  bladder,  a  catheter  should  be  introduced  or  drainage  be 
obtained  through  a  perineal  incision.  I  prefer  continuous  catheterization  through 
the  urethra  to  making  a  perineal  section.  In  these  days  of  clean  surgery  and 
skilful  nursing  one  need  have  little  apprehension  that  the  catheter,  when  properly 
handled,  will  cause  chills  or  produce  urethral  irritation. 

In  one  of  my  cases  the  bladder  was  tunneled  for  two  inches,  but  other  than  the 
time  recjuired  in  making  the  repair  it  did  not  seem  to  comphcate  matters  in  the  least. 
Two  of  the  fatal  cases  in  the  Grady  Hospital  statistics  quoted  below  were  due  to 
failure  to  find  and  properly  deal  with  bladder  injuries. 

Injuries  to  the  solid  viscera  other  than  the  kidney  and  pancreas  are  dangerous 
chiefly  on  account  of  hemorrhage. 

Bleeding  from  the  liver  can  usually  be  controlled  by  light  gauze  packing.  Where 
this  does  not  suffice,  deep  through-and-through  heavy  catgut  sutures  loosely  tied, 
or  the  tape  suture  of  Tiffany,  may  be  necessary.  Strips  of  gauze  packed  in  or  about 
bleeding  points  in  the  solid  viscera  should  be  brought  out  through  the  abdominal 
wound  for  drainage.  Injury  to  the  spleen  or  its  vessels  causing  free  bleeding  which 
cannot  be  controlled  readily  by  packing  or  suture  is  an  indication  for  splenectomy. 
Temporizing  with  such  a  condition  is  unwarranted.  It  is  a  serious  complication, 
but  by  no  means  an  absolute  barrier  to  recovery.  The  immediate  and  remote 
results  following  splenectomy  for  injury  have  been  remarkably  good. 

Injuries  to  the  pancreas  are  very  difficult  to  handle  properly  and  consequently 
they  are  peculiarly  fatal.  When  the  pancreas  has  been  injured  the  wound  in  it 
should  be  packed  and  both  anterior  and  posterior  drainage  should  be  made  (through- 
and-through  drainage).     (See  Chapter  XXXVI.) 


644  PENETRATING    WOUNDS    OF   THE    ABDOMEN. 

Superficial  injuries  to  the  cortical  substance  of  the  kidney  should  be  drained 
through  the  loin.  It  is  dangerous  to  attempt  to  drain  a  kidney  transperitoneally. 
When  there  is  extensive  laceration  of  the  kidney  substance,  and  when  the  renal  vessels 
are  severed,  a  nephrectomy  should  be  done.  Temporizing  with  a  kidney  thus  in- 
jured will  usually  lead  to  a  fatal  result.  [It  has  been  advised  to  remove  the  kidney 
when  its  pelvis  is  torn.  As  a  rule,  it  is  proper  to  suture  the  pelvis  with  chromic  catgut 
and  to  drain  through  the  loin.  A  secondary  nephrectomy  may  be  required. — Ed.] 
An  essential  to  success  in  the  treatment  of  penetrating  wounds  of  the  abdomen  is  a 
proper  peritoneal  toilet.  The  extensive  washings  out  formerly  advocated  are  now 
no  longer  sanctioned  by  good  practice  except  in  the  presence  of  excessive  soiling 
with  intestinal  contents,  or  in  cases  of  very  general  or  universal  peritonitis.  Better 
results  follow  careful  local  toilet,  wiping  infected  areas  carefully  with  moist  sponges, 
than  can  be  obtained  by  attempts  at  washing  out  the  entire  peritoneal  cavity.  Such 
attempts  at  washing  out  tend  to  spread  what  might  otherwise  be  a  local  infection 
to  widely  separated  dependent  portions  of  the  peritoneal  cavity  and  to  convert  a 
local  into  a  general  infection.  When  a  large  quantity  of  water  is  introduced  into  the 
abdominal  cavity  the  intestines  are  often  forced  out  through  the  incision  and  can  be 
replaced  only  with  considerable  difficulty  and  trauma. 

The  question  of  drainage  must  be  determined  by  the  conditions  obtaining  in 
individual  cases.  When  the  perforations  are  small,  the  intestinal  tract  compara- 
tively empty,  the  closures  accurately  done,  with  little  handling  and  soiling  of  the 
peritoneum,  I  close  without  drainage.  When  there  are  bleeding  vessels  that  cannot 
be  tied  accurately,  when  there  is  extensive  soiling  of  the  peritoneum,  and  wide- 
spread peritonitis  exists,  it  is  safer  to  place  one  or  more  cigarette  gauze  drains. 

It  is  a  good  rule  to  look  for  an  even  number  of  perforations. 

Of  first  importance  in  the  after-treatment  of  penetrating  wounds  of  the  abdomen 
is  rest,  general  and  alimentary.  When  the  injury  is  in  the  upper  part  of  the 
intestinal  tract  nothing  should  be  allowed  by  the  mouth  except  sterile  water  for 
several  days.  The  lower  bowel  should  be  kept  unloaded  by  simple  enemata  and 
rectal  feeding  should  be  employed.  Purgatives  must  be  avoided.  A  little  mor- 
phin  or  codein  may  be  necessary  to  relieve  great  pain  and  to  secure  proper  rest. 
Opiates,  however,  ought  to  be  given  very  guardedly.  Strychnin  is  usually  indicated. 
When  there  has  been  considerable  hemorrhage,  if  practicable,  a  quantity  of  normal 
salt  solution  should  be  left  in  the  abdomen.  Normal  salt  solution  should  be  given 
by  hypodermoclysis  or  by  intravenous  transfusion  as  indicated.  When  there  has 
been  excessive  hemorrhage,  lives  may  often  be  saved  by  the  free  use  of  normal  salt 
solution.  In  the  presence  of  injury  to  the  large  bowel  it  is  best  to  give  simple  sterile 
food  by  the  mouth,  that  is  readily  absorbable  from  the  stomach,  and  to  introduce 
nothing  into  the  bowel  jper  anum  lest  the  wound  in  the  large  bowel  be  forced  open. 

In  the  after-treatment  of  these  cases,  when  there  is  marked  gaseous  distention, 
with  a  tendency  to  intestinal  paresis,  alum  enemata,  as  first  suggested  by  the  late 
Virgil  O.  Hardon,  of  Atlanta,  are  of  great  value.  Sulphate  or  salicylate  of  eserin  in 
dose  of  one  one-hundredth  of  a  grain,  every  three   to  six  hours,  has  seemed  to 


PROGNOSIS. 


645 


have  a  salutary  effect.  I  absolutely  exclude  milk  and  egg  diet  by  the  mouth  for 
the  first  five  to  eight  days.  Milk  and  eggs  tend  to  increase  the  formation  of  gas  and 
to  constipate  the  bowels. 

Purgatives  should  be  employed  with  great  care  and  only  after  four  to  six  days 
following  the  operation. 

Prognosis. — It  is  unfair  to  quote  military  statistics  as  an  argument  against 
operations  in  civil  life.  The  conditions  under  which  the  injuries  are  received  and 
the  character  of  the  injuries  are  so  different  as  hardly  to  admit  of  just  comparison. 
In  modern  military  practice  the  abdominal  injuries  are  due  to  small-caliber,  steel- 
jacketed  bullets  of  high  velocity,  which  go  directly  through,  making  small,  clean- 
cut  perforations  in  the  hollow  as  well  as  the  solid  viscera,  from  which  there  is  very 
little  leakage  or  hemorrhage.  The  injuries  are  more  frequently  than  otherwise 
received  in  the  standing  posture,  with  a  comparatively  empty  intestinal  tract,  by 
individuals  in  the  prime  of  life — picked  specimens  of  physical  manhood.  In  civil 
practice  the  individuals  are  more  frequently  than  otherwise  shot  in  drunken  brawls, 
when  the  ahmentary  canal  is  filled  with  alcohol  and  with  all  sorts  of  irritating  and 
even  infectious  material.  The  wounds  are  made  by  infected  bullets,  which  have 
been  carried  around  in  the  hip  pocket  by  "pistol  toters,"  of  large  caliber  and  low 
velocity,  that  make  large,  ragged  perforations  in  the  hollow  viscera  and  jagged 
wounds  in  the  mesentery  and  solid  viscera  that  leak  freely  and  bleed  furiously. 
Other  things  being  equal,  the  surgeon  who  opens  the  abdomen  the  earliest  after 
the  injury,  does  his  work  rapidly  and  accurately,  and  who  closes  the  abdomen  in 
the  shortest  time,  will  get  the  best  results   as  to  mortality. 

The  prognosis  of  penetrating  gunshot  wounds  made  by  large-caliber,  low- 
velocity  bullets  without  operation,  is  bad.  As  shown  by  the  accompanying  statis- 
tics of  the  Crimean  War,  the  American  Civil  War,  and  civil  hospitals,  about  90  per 
cent,  prove  fatal.  Stab  wounds  and  wounds  made  by  small  shot,  or  small-caliber, 
steel-jacketed,  high-velocity  bullets  are  less  fatal,  giving  a  mortality  of  from  50  to 
75  per  cent.  Wounds  of  the  umbilical  and  hypogastric  regions  are  peculiarly  dan- 
gerous.    In  these  regions  the  small  intestines  rarely  escape  perforation. 


Penetrating  Abdominal  Wounds. 


Crimean  War 

Italian  War 

Civil  War. 

Franco-Prussian  War. . 
Spanish-American  War 


Number. 

Deaths. 

241 

222 

246 

163 

3717 

3031 

1047 

784 

115 

81 

Mortality. 

92.1% 

87.2% 
87.2% 
74.8% 
69.8% 


Of  the  113  cases  in  the  Spanish- American  War  13  cases  had  operations  with  11 
deaths — a  mortality  of  S4.6  per  cent.  Of  the  103  cases  not  operated  upon,  70 
died — a  mortality  of  67.9  per  cent. 

The  contents  of  the  stomach  are  comparatively  innocuous.  The  virulence  of 
the  infection  contained  in  the  alimentary  canal  progressively  increases  to  the  ileo- 


646 


PENETRATING    WOUNDS    OF   THE   ABDOMEN. 


cecal  junction;  the  contents  of  the  large  intestine  are  less  infectious,  and  wounds  of 
the  large  intestine  are  less  often  fatal,  than  are  those  of  the  small  intestine. 


Penetrating  Abdominal 
Wounds. 

Operation. 

Deaths. 

Mortality. 

No   Opera- 
tion. 

Deaths. 

Mortality. 

Grady  Hospital  cases. .  . 
McRae's  private  cases.  . 

31 
11 

8 
4 

25.8% 
36.5% 

16 
5 

10 

4 

62.5% 
80.0% 

In  looking  over  the  statistics  of  the  Grady  Hospital,  I  find  that  there  have  been 
since  July,  1899,  forty-seven  cases  of  penetrating  wounds  of  the  abdomen.  Thirty- 
one  of  these  were  operated  upon,  with  a  mortality  of  25.8  per  cent.  Sixteen  were  not 
operated  upon,  with  a  mortality  of  62.5  per  cent.  Not  a  single  death  could  have 
been  attributed  to  the  operation  'per  se.  In  one  fatal  case  a  perforation  of  the  gall- 
bladder was  overlooked.  In  two  fatal  cases  injuries  to  the  urinary  bladder  were 
overlooked.  In  two  cases  the  deaths  were  evidently  due  to  kidney  injuries,  with 
leakage  of  urine  into  the  peritoneal  cavity,  which  were  overlooked.  In  one  case 
intestinal  perforations  were  overlooked.  In  another  case  the  abdomen  was  opened, 
found  filled  with  blood,  the  blood  washed  out,  and  the  abdomen  closed,  without 
finding  the  source  of  hemorrhage,  the  patient  subsequently  dying  from  internal 
hemorrhage. 

These  thirty-one  operations  have  been  done  by  eight  different  surgeons  and  three 
house  surgeons  (in  turn) ;  this  large  number  of  operators  giving  only  a  fair  average 
of  surgical  skill.  In  spite  of  the  fatalities  due  to  overlooked  injuries,  the  statistics 
following  operations  have  been  very  gratifying  and  have  constantly  improved. 
The  cases  not  operated  upon  were  either  very  bad  cases  or  those  in  which  the  wound 
was  in  such  a  locality  as  to  indicate  no  injury  to  important  viscera;  for  instance, 
well  out  in  the  lumbar  region,  high  up  in  the  hypochondriac  region,  or  in  the  epi- 
gastric region.  The  cases  operated  upon  have  been  worse  as  a  class  than  those 
treated  expectantly. 

The  contraindications  to  operation  are  bad  surroundings,  incompetent  help, 
and  the  lapse  of  twelve  hours  or  more  between  the  receipt  of  the  injury  and  possi- 
ble surgical  aid.  Other  things  being  equal,  the  mortality  is  in  direct  proportion  to 
the  length  of  time  elapsing  between  the  receipt  of  the  injury  and  surgical  interven- 
tion. After  eighteen  to  twenty-four  hours  the  mortality  is  so  great  that  operation 
should  be  undertaken  only  when  something  positive  can  be  accomplished  by  it. 
After  this  lapse  of  time.  Nature  has  often  done  her  best  to  repair  the  damage,  and 
an  operation  increases  the  hazard. 

My  personal  experience  and  responsibility  cover  but  sixteen  cases.  I  have, 
however,  had  intimate  knowledge  of  most  of  the  forty-seven  Grady  Hospital  cases 
recorded  below,  and  have  assisted  or  been  present  at  many  of  the  operations  done  by 
other  surgeons  and  have  followed  the  cases  in  the  wards.  I  have  been  forced  by 
these  observations  and  experience  from  an  attitude  favoring  expectant  treatment  to 
a  position  of  earnest  advocacy  of  early  operation,  in  all  penetrating  wounds  of  the 


PROGNOSIS.  647 

abdomen,  unless  positively  contraindicated  by  the  individual's  physical  condition 
and  surroundings,  or  by  the  absence  of  a  competent  abdominal  surgeon  and  assist- 
ants. 

Of  my  sixteen  cases,  eight  had  the  benefit  of  early  operation,  with  seven  recoveries. 
The  percentage  of  recoveries  was  87.5. 

Six  of  the  eight  operations  were  for  rifle  or  pistol-shot  wounds,  and  all  presented 
grave  visceral  lesions.  One  had  an  extensive  laceration  of  the  liver,  with  excessive 
hemorrhage,  the  patient  exsanguinated  and  pulseless  at  wrist — recovery.  One 
had  three  perforations  in  stomach  with  leakage — recovery.  Four  had  multiple  per- 
forations in  the  small  intestines  with  leakage  in  all — three  recoveries,  one  death.  In 
one  of  the  above  the  bladder  was  also  injured — recovery. 

Two  operations  were  done  for  stab  wounds  of  the  liver.  Free  hemorrhage  in 
both  cases  was  controlled  by  suture  of  the  liver  wounds  and  gauze  packing- — both 
recovered. 

I  have  treated  four  pistol-shot  wounds  of  the  abdomen  expectantly,  with  three 
deaths  and  one  recovery.  One  man  with  a  stab  wound  treated  expectantly  died. 
This  makes  five  cases  treated  expectantly,  with  four  deaths  and  one  recovery — 80 
per  cent,  mortality. 

I  have  done  two  late  operations  for  complications  due  to  penetrating  wounds 
that  might  have  been  prevented  by  early  operation.  Both  died — mortality  100  per 
cent. 

The  above  statistics,  my  personal  experience,  observation  of  our  Grady  Hospital 
cases,  and  a  careful  review  of  the  literature  on  penetrating  wounds  of  the  abdomen, 
abstracted  below,  have  led  me  to  make  the  following  conclusions  as  to  civil  practice: 

1.  In  civil  practice  every  suspected  penetrating  wound  of  the  abdomen,  under 
favorable  conditions,  should  have  the  benefit  of  wound  tracing. 

2.  When  the  wound  proves  to  be  penetrating,  an  exploratory  laparotomy  should 
be  done  at  once  and  visceral  damage  excluded  or  repaired  as  far  as  practicable. 

3.  There  is  far  less  danger  from  "wound  tracing"  than  there  is  from  probing  or 
from  "masterly  inactivity,"  while  awaiting  positive  evidence  of  visceral  damage 
which  requires  operative  interference. 

4.  Local  toilet  with  moist  sponging  for  cleansing  is  better  than  free  peritoneal 
irrigation. 

5.  When  in  doubt  it  is  safer  to  drain. 

6.  Operations  done  within  two  hours  should  not  give  a  mortality  over  25  to  30 
per  cent.,  within  four  hours  over  40  per  cent.,  within  six  hours  over  50  per  cent., 
within  eight  hours  over  60  per  cent.,  and  within  twelve  hours  over  70  per  cent. 

7.  After  twelve  hours  expectant  treatment  is  best  unless  there  is  some  definite 
indication  for  operation. 

The  above  deductions  do  not  apply  to  military  practice.  Expectant  treatment 
in  military  practice  has  given  better  results  with  wounds  made  by  modern  arms 
than  has  operative  treatment. 

It  does  seem,  however,  that  a  mortality  of  75  per  cent,  in  military  practice  under 


648  PENETRATING    WOUNDS    OF   THE    ABDOMEN. 

the  expectant  plan  of  treatment  is  too  great,  and  ought  to  be  reduced  in  future  war- 
fare by  thorough  organization  and  equipment  of  the  medical  department,  prompt 
ambulance  service,  aseptic  first  aid,  well  appointed  field  hospitals  in  charge  of  com- 
petent abdominal  surgeons  and  nurses,  and  a  proper  selection  of  cases  for  expectant 
treatment  and  for  laparotomy. 

ABSTRACT  OF  THE  LITERATURE  OF  PENETRATING  WOUNDS  OF  THE 

ABDOMEN. 

The  following  abstracts  give  the  history  of  the  development  of  the  modern  treat- 
ment of  penetrating  wounds  of  the  abdomen,  and  in  addition  give  a  clearer  insight 
into  the  actual  basis  of  the  present  teachings  upon  this  subject  than  can  be  afforded 
by  a  summary  statement  such  as  has  been  made  in  the  preceding  pages. 

Sims^  said:  "Given  a  case  of  perforation  of  the  intestine  in  such  a  man  as  Gen. 
McClellan;  and  given  a  correct  diagnosis,  which  is  by  no  means  difficult;  what 
are  we  to  do  in  the  present  state  of  our  knowledge?  Why,  of  course,  we  should 
open  the  abdomen  promptly,  clean  out  the  peritoneal  cavity,  search  for  the  perfo- 
ration, pare  its  edges,  and  bring  them  together  with  sutures;  and  treat  the  case  as 
we  now  treat  other  cases  involving  the  peritoneum.-  Rest  assured  that  the  day 
will  come,  and  it  is  not  far  off,  when  an  accurate  diagnosis  in  such  cases,  followed 
by  prompt  action,  will  save  life  that  otherwise  must  quickly  ebb  away,  and  the  same 
thing  must  be  done  in  gunshot  wounds  of  the  abdomen. 

"Death  from  wounds  of  the  abdomen  may  occur  from  shock,  from  hemor- 
rhage, or  from  septicemia;  seldom  from  peritonitis,  properly  speaking.  When 
from  shock  or  hemorrhage,  there  is  no  reaction  and  death  is  comparatively  sudden. 
Reaction  once  established,  shock  is  over  and  direct  danger  from  hemorrhage  is 
past.  The  great  danger  is  from  septicemia  from  effusion  into  the  peritoneum. 
Some  years  ago  it  was  thought  that  peritonitis  was  the  chief  cause  of  death  after  ova- 
riotomy. But  this  is  not  the  accepted  doctrine  of  today.  Death  in  these  cases  is 
due  to  septicemia  and  not  peritonitis,  septicemia  caused  by  bloody  serous  fluids  in 
the  pelvic  cavity. 

"Why  should  not  other  wounds  of  the  abdomen  cause  death  in  the  same  way 
as  those  made  by  the  ovariotomy  ?  I  was  convinced  that  we  should  find  the  same 
appearance  in  shot  and  other  wounds  of  the  abdomen  that  we  found  in  fatal  cases 
of  ovariotomy." 

Sims  related  two  cases  of  gunshot  wounds  of  the  abdomen,  both  resulting  in 
death,  one  case  living  five  days,  the  other  eighteen  hours.  At  the  autopsy  in  both 
cases  there  was  an  effusion  of  bloody  serous  fluid  into  the  peritoneal  cavity.  The 
sudden  outpouring  of  flatus  into  the  abdominal  cavity  and  extravasated  fluids  even 
in  small  quantities  is  sufficient  for  a  septicemia.  He  said:  "It  is  not  the  quantity, 
but  the  quality,  of  the  exudate  that  kills.  There  is  no  reason  why  the  system  should 
not  be  overwhelmed  by  the  absorption  of  concentrated  septic  material  as  by  an  over- 
dose of  morphin. 

1  Sims,  J.  M.:  Brit.  Med.  Jour.,  1881,  ii,  925.  ^  Lq^   pj^..  p.  3. 


ABSTRACT    OF    LITERATURE    OF   PENETRATING    WOUNDS    OF   ABDOMEN.  64& 

"It  is  necessary  to  reopen  the  abdomen  after  ovariotomy  and  allow  the  bloody 
serous  fluid  to  escape,  and  it  is  necessary  to  open  the  abdomen  and  allow  the  escape 
of  pus  when  peritonitis  exists.  It  is  possible  that  the  escape  of  flatus  and  contents 
of  the  intestine  into  the  bloody  fluid  gives  an  intensity  to  the  poisonous  qualities 
that  it  would  not  otherwise  have." 

In  1S72  Sims  said:  "The  danger  consists  not  in  opening  the  aljdominal  cavity,. 
but  in  keeping  it  closed,  and  the  day  will  come  when  gunshot  and  other  wounds  of 
the  abdomen  and  perforations  of  the  intestine  will  be  treated  by  opening  the  perito- 
neal cavity,  and  washing  out  or  drainage  of  the  septic  fluids. 

"Do  men  ever  recover  spontaneously  from  gunshot  wounds  of  the  abdomen 
perforating  the  peritoneal  cavity  ?  Rarely  indeed,  if  the  bowel  be  wounded  above 
the  brim  of  the  pelvis."  At  Sedan  seven  cases  of  shot  wounds  of  the  abdomen 
occurred,  and  they  all  died,  most  of  them  within  twenty-four  hours.  There  were 
several  cases  of  recovery  where  balls  passed  through  the  pelvis,  wounding  the  blad- 
der or  bowel,  or  both,  but  no  recovery  where  the  wound  was  above  the  brim  of  the 
pelvis.     Of  seven  shot  through  the  pelvis,  all  recovered. 

"Why  do  patients  shot  through  the  pelvis  live  and  those  through  the  abdomen 
die  ?  In  the  first  case  there  is  natural  drainage  of  septic  matter  directly  from  the 
pelvic  cavity  along  the  track  of  the  ball,  and  the  patient  lives.  In  the  other  case, 
drainage  is  impossible,  because  the  septic  matter  falls  into  the  pelvic  cavity,  is  there 
retained  and  then  absorbed,  and  the  patient  dies  of  blood  poisoning.  Occasionally 
wounds  of  the  abdomen  recover,  but  it  is  always  when  there  is  a  chance  for  drain- 
age." 

Wounds  of  the  Stomach. — There  were  64  shot  wounds  of  the  stomach  com- 
plicated with  wounds  of  neighboring  parts,  with  but  one  well-authenticated  case  of 
recovery.  Of  nine  cases  of  bayonet  wounds  penetrating  the  peritoneal  cavitv 
without  visceral  lesion,  six  terminated  favorably;  seven  of  them  had  traumatic 
peritonitis.  The  diagnosis  was  not  clear  in  all  cases.  There  were  four  fatal  punc- 
ture wounds  of  the  stomach.  Five  men  having  fatal  shot  wounds  are  reported 
as  having  survived  respectively  seven,  eight,  nine,  and  forty  days.  There  was  not  a 
single  gastrorrhaphy  during  the  war.  Three  men  with  secondary  gastric  fistulse 
lived  respectively  four  weeks,  seven  weeks,  and  eighty  days.  Otis  sums  up  his 
conclusions  concerning  wounds  of  the  stomach  in  the  following  words:  There 
were  four  fatal  punctured  or  incised  wounds;  one  incontestable  recovery  from  a 
shot  perforation;  a  few  recoveries  from  shot  wounds  in  the  gastric  region  in  which 
the  diagnosis  was  not  determined  unequivocally;  and  nearly  sixty  fatal  cases  of 
more  or  less  complicated  shot  wounds  of  stomach. 

The  records  of  military  surgery  (according  to  Otis),  from  its  earliest  period  to 
the  present  time,  furnish  but  six  or  seven  well-authenticated  cases  of  recovery  from 
shot  wounds  of  the  stomach,  with  or  without  fistula. 

Wounds  of  Small  Intestine. — "Of  about  650  cases  of  penetrating  wounds  of 
the  abdomen  during  the  war,  fifty  were  of  the  small  intestine;  S9  of  large  intestine, 
and  over  500  in  which  the  location  of  the  wound  was  not  discriminated,  or  was 


650  PENETRATING    WOUNDS    OF   THE    ABDOMEN. 

complicated  with  other  lesions."  Wounds  of  the  small  intestine  are  more  frequent 
and  are  attended  with  a  higher  mortality.  Otis  says  that  "it  may  still  be  doubtful 
if  an  incontestable  instance  of  recovery  was  observed." 

Wounds  of  Large  Intestine. — Injuries  of  this  group  are  less  fatal  than  wounds 
of  the  small  intestine ;  four  instances  are  recorded  of  recovery  from  shot  wounds  of 
the  transverse  colon;  many  after  perforation  of  the  cecum  and  ascending  portion 
of  bowel;  and  a  still  larger  number  after  wounds  of  the  sigmoid  and  contiguous 
parts.  Nearly  all  resulted  in  fecal  fistulse,  eventually  closing.  The  fistulse  per- 
sisted in  nine  and  closed  in  fifty.  Ten  per  cent,  of  those  slain  in  battle  die  of  wounds 
of  the  abdomen. 

Wounds  of  Bladder. — There  is  no  recorded  case  of  punctured  wound  of  the 
bladder  in  the  Civil  War.  Of  183  shot  wounds,  87  survived.  Many  of  those  sur- 
viving suffered  from  grave  disabilities,  e.  g.,  urinary  fistulse.  It  is  rare  to  find 
functions  of  the  bladder  entirely  restored  after  shot  injuries.  There  were  21  cystot- 
omies for  removal  of  foreign  bodies.     Cystorrhaphy  was  not  practised. 

Shot  Wounds  of  Rectum. — There  are  103  cases  reported,  of  which  44  resulted 
fatally.  Thirty-four  of  the  cases,  of  which  four  died,  were  complicated  with  wounds 
of  the  bladder.  Fecal  fistulse  were  not  uncommon.  Shot  wounds  of  the  rectum 
are  not  so  dangerous  as  those  of  the  upper  bowel. 

Gastrorrhaphy. — Few  recoveries  followed  punctured  wounds;  none  followed 
shot  wounds. 

Enterorrhaphy. — Otis  says  there  were  32  American  instances  of  enterorrhaphy 
of  the  small  intestine,  of  which  25  were  successful.  In  all  of  them  the  bowel  had 
prolapsed  through  punctured  or  incised  wounds,  and  was  sutured,  and  returned 
to  the  peritoneal  cavity.  They  occurred  between  1807  and  1869.  Many  cases  are 
recorded  where  the  prolapsed  bowel  was  sutured  and  returned  to  the  abdomen, 
yet  the  patients  died — death  being  due  to  other  perforations.  Penetrating  wounds 
are  generally  multiple  and  "show  the  absolute  necessity  of  enlarging  external 
wounds  sufficiently  for  exploration."  The  records  of  the  Civil  War  teem  with 
reports  of  shot  wounds  of  the  intestines  in  which  the  victim  lived  for  days,  and 
finally  died  of  exhaustion  and  blood-poisoning. 

Senn^  says:  "  Clinical  experience  and  the  result  of  experiment  show  conclusively 
that  laparotomy  should  not  be  performed  simply  because  a  bullet  has  entered  the 
abdominal  cavity,  but  that  its  performance  should  be  limited  to  the  treatment  of 
intra-abdominal  lesions,  which,  without  operative  interference,  would  tend  to  destroy 
life.  A  bullet  passing  through  tKe  lower  abdomen  is  always  sure  to  cause  some 
perforation,  while  if  it  enters  antero-posteriorly  at  or  a  little  above  the  umbilicus, 
it  may  be  inferred  with  some  degree  of  probability  that  there  is  an  absence  of  severe 
visceral  complication." 

Klemm^  gives  an  able  digest  of  the  literature  as  well  as  his  results  when  working 

*  Senn,  Nicholas:  "The  Modern  Treatment  of  Gunshot  Wounds  in  MiHtary  Practice,"  Jour. 
Amer.  Med.  Assoc,  July  9,  1898,  xxxi. 

2  Klemm,  Paul:  "Gunshot  Abdominal  Wounds — Experimental  Results,"  Volkmann's  Samm- 
lunsf  klinischer  Vortriige,  1896,  No.  142. 


ABSTRACT    OF    LITERATURE    OF    PENETRATING   WOUNDS    OF   ABDOMEN.  651 

experimentally  with  dogs.  He  says:  Few  laparotomies  were  performed  for  gunshot 
wounds  until  after  the  American  Civil  War.  German  and  American  surgeons 
advise  laparotomy  for  these  cases,  while  the  French,  championed  by  Reclus,  say 
that  the  expectant  method  gives  a  smaller  mortality,  arguing  that  during  an  injury 
to  a  hollow  viscus  a  plug  of  mucous  membrane  protrudes  through  the  wound  and 
closes  it.  Klemm  showed  experimentally  that  such  a  plug  could  be  and  was  pro- 
duced, but  it  by  no  means  closed  the  wound  in  the  intestine  nor  successfully  pre- 
vented leakage.  In  the  majority  of  gunshot  wounds  of  the  abdomen,  various 
viscera  are  injured. 

Liihe  observed  152  cases  clinically,  and  only  in  three  was  there  no  injury;  in 
110  cases  these  perforations  were  multiple.  The  size  of  the  wound  in  the  gut  is 
determined  by:  (1)  The  angle  at  which  the  bullet  strikes  it;  (2)  the  diameter  at 
the  point  struck. 

He  advises  immediate  operation  in  all  cases  in  which  the  patient's  condition  will 
permit. 

When  peritonitis  already  exists  or  when  a  patient  is  weakened  by  a  complica- 
tion such  as  septic  intoxication,  operation  is  contraindicated. 

Parker^  divides  the  cases,  as  they  present  themselves,  into  three  classes,  the 
early,  the  intermediate,  and  the  late — the  early  being  seen  not  more  than  seven  hours 
after  injury,  the  intermediate  between  seven  and  fourteen,  the  late  after  fourteen 
hours.  He  believes  that  a  penetrating  wound  of  the  abdomen  is  best  treated  by 
operation,  before  symptoms  develop. 

He  gives  a  series  of  tables  and  a  summary  of  thirteen  cases  personally  observed 
and  operated  upon,  with  seven  deaths — a  mortality  of  54.6  per  cent. 

Two  cases  with  wounds  of  large  intestine both  died. 

Eight     "         "  "       "  small  "      four      " 

Two       "         "  "       "  stomach  one       " 

One  case  with  no  visceral  injury recovered. 

He  then  reports  the  collected  results  of  145  cases  operated  upon  with  a  mortality 
of  53.1  per  cent. 
Of  these  cases: 

41  cases  wounds  of  small  intestine  within  seven  hours 51.2%  mortality. 

22  cases  after  fourteen  hours 81.8%  " 

10  cases  wounds  of  large  intestine  within  seven  hours 20    %  " 

2  cases  after  fourteen  hours 100    %  " 

11  cases  wounds  of  stomach  within  seven  hours 27.2%  " 

5  cases  after  fourteen  hours 80    %  " 

13  cases  bowel  resected  within  seven  hours  after  injury 86.8%  " 

Grant^  says  that  for  all  practical  purposes  the  intestines,  in  penetrating  wounds 
of  the  abdomen,  will  be  injured  in  73.2  per  cent,  of  cases;  the  solid  viscera  or  intes- 
tines, in  99.8  per  cent.     He  advises  immediate  operation.     The  ordinary  symptoms 

'Parker,  W.  E.:  "Gunshot  Wounds  of  Abdomen,"  Southern  Surg,  and  Gvn.  Transact., 
1896,  ix,  272. 

^  Grant,  H.  H.:  "The  Practical  Management  of  Bullet  Wounds  of  the  Abdominal  Viscera," 
Southern  Surg,  and  Gyn.  Transact.,  1898,  xi,  39. 


652  PENETRATING   WOUNDS    OF   THE    ABDOMEN. 

of  perforation  should  not  be  waited  for.  Shock,  pallor,  vomiting,  and  severe  pain 
may  all  be  absent. 

He  reports  four  personal  cases  operated  on  within  seven  hours  with  one  death. 
In  the  fatal  case  the  intestines  were  greatly  distended  with  fecal  material. 

Two  other  cases  are  reported:  One  wound  of  stomach  and  a  large  tear  of  the 
duodenum;  one  perforating  wound  of  stomach,  with  liver  wounded,  and  three 
wounds  of  intestine  sutured — recovered. 

Total,  six  cases — one  death — 16j  per  cent,  mortality. 

Winslow^  says :  As  a  rule  the  traumatism  from  a  gunshot  wound  is  greater  than 
from  a  cutting  wound  and  the  mortality  is  higher. 

Symptoms. — The  most  obvious  symptom  is  the  location  of  the  wound  of  entrance. 
The  presence  of  a  gunshot  wound  of  the  anterior  abdominal  wall  is  enough  to  de- 
mand exploration,  and  if  penetrating,  laparotomy  should  at  once  be  performed. 

Prognosis. — The  symptoms  depend  upon  the  nature  of  the  traumatism,  the 
organs  and  tissues  injured,  the  degree  of  emptiness  or  fullness  of  hollow  viscera 
when  injured,  and  upon  the  presence  or  absence  of  serious  hemorrhage.  Gunshot 
wounds  of  the  intestine  in  civil  practice  are  usually  fatal  if  not  operated  upon.  In 
the  Civil  War  gunshot  wounds  of  both  intestines  had  a  mortality  of  80.3  per  cent., 
while  the  same  injuries  of  the  small  intestine  had  a  mortality  of  100  per  cent. 

In  recent  military  practice  the  prognosis  and  treatment  are  modified  because  of 
the  small  caliber  of  the  projectile,  with  steel  or  nickel  jacket,  and  of  the  greater 
velocity  with  which  it  is  propelled  by  the  modern  rifle.  The  long  narrow  bullet, 
projected  with  great  speed,  penetrates  the  tissues  cleanly,  does  not  become  deflected, 
and  is  usually  aseptic. 

In  civil  practice  the  bullets  are  generally  large,  the  velocity  is  low,  and  the  lacera- 
tion more  extensive.  Penetrating,  stab,  and  gunshot  wounds  occurring  in  civil 
life  should  be  operated  upon  at  once. 

Total  cases,  29 

5,  no  operation :  4  died 80    % 

25  operated  upon,  9  died 37.5% 

4  stab  wounds  operated  upon,  4  recovered 100    % 

Rodman^  divides  gunshot  wounds  into  penetrating  and  perforating  wounds. 
Of  the  penetrating  wounds  a  vast  majority  are  perforating — at  least  97  per  cent., 
according  to  Douglas.  Penetration  without  perforation,  even  with  large  balls, 
does  occur,  as  such  cases  have  been  reported  by  Senn,  Stimson,  Oliver,  ]\IcGuire, 
and  others.     Wounds  above  the  umbilicus  are  less  likely  to  be  perforating. 

Sir  Fred.  Treves,  Sir  Wm.  ]MacCormack,  and  other  British  surgeons,  as  a  result 
of  experience  in  South  Africa,  and  Senn,  Parker,  Nancrede,  and  LaGarde,  all  saw 
penetrating  wounds,  which  apparently  were  perforating,  recover.  At  least  91  per 
cent,  of  penetrating  wounds  are  perforating;    65  per  cent,  injure  the  intestine. 

^  VY''inslow,  R.:  "Penetrating  Wounds  of  the  Abdomen,"  Jour.  Amer.  Med.  Assoc,  1905,  xlv, 
1048. 

^  Rodman,  W.  L.:  "Gunshot  Wounds  of  the  Thorax  and  Abdomen  from  the  Viewpoint  of  a 
Civil  Surgeon,"  Jour.  Amer.  Med.  Assoc,  1902,  xl,  415-425. 


ABSTRACT    OF    LITERATURE    OF    PENETRATING    WOUNDS    OF   ABDOMEN.         653 

The  prognosis  is  always  grave.  Wounds  of  the  hver,  colon,  and  rectum  are  not 
as  fatal  as  wounds  of  the  small  intestine.  The  prognosis  is  better  in  wounds  above 
the  umbilicus  than  in  those  below.  Antero-posterior  wounds  are  less  dangerous 
than  oblique  ones;   those  from  flank  to  flank  are  most  serious. 

On  penetrating  wounds  of  the  abdomen  Seigel's  statistics  show  that  of  537 
cases  not  subjected  to  operation  55.2  per  cent,  were  fatal;  of  763  cases  subjected 
to  laparotomy  51.6  per  cent,  were  fatal.  Douglas'  more  recent  statistics,  compiled 
from  the  literature  since  1895,  record  65  cases,  of  wliich  44  recovered  and  21  died — a 
mortality  of  32.3  per  cent. 

Seigel's  statistics  show: 

Operation,  first       4  hours 15.2%  mortality. 

5  to       8      "     44.4% 

9  to     12      "     63.6%, 

after  12      " 70% 

Brown^  says :  The  question  to  determine  is  not  when  to  operate,  but  how  and  by 
what  surgical  methods  we  can  best  meet  the  indications  of  such  cases. 

He  reports  9  cases  of  wounds  of  the  intestine,  of  which  4  died,  3  were  in  a  critical 
condition  at  the  time  of  operation,  and  1  died  of  pneumonia  thirteen  days  after 
■operation. 

There  were: 

5  cases  of  wounds  of  liver:  4  recovered,  1  died. 
8  cases   operated  upon:  no   wounds   of   viscera   found,   all   re- 
covered. 
23  cases  operated  upon:  19  recovered,  4  died 17.4%  mortality. 

Brennfleck"  gives  a  general  review  of  splenectomies  for  injuries  and  reports  a 
-case  in  which  splenectomy  was  done  for  a  gunshot  wound  of  the  abdomen  injuring 
the  spleen. 

Blood  examinations  at  various  times  showed  no  great  variation  from  the  normal. 

He  concludes  from  his  case  and  the  literature  that  removal  of  the  injured  spleen 
is  an  operation  neither  dangerous  to  life  nor  injurious  to  the  organism. 

DeWreden^  says:  The  small-caliber  mantle  bullets  were  intended  to  mercifully 
remove  the  greatest  number  of  men  possible,  for  a  more  or  less  considerable  period 
of  time,  out  of  the  ranks  of  combatants.  The  Russian-Japanese  War  has  completely 
demonstrated  the  destructive  character  of  these  bidlets,  which  tear  and  comminute 
and  become  deformed  relative  to  the  distance  and  quality  of  the  obstacle  they  meet. 

Wounds  of  the  abdomen  inflicted  from  a  distance  up  to  two  hundred  steps  are 
absolutely  mortal,  on  account  of  an  explosive  effect  of  the  bullet  distinctly  expressed 
at  such  a  distance  on  intestines,  urinary  passages,  and  parenchymatous  organs. 
With  the  increase  of  distance,  and  subject  to  the  degree  of  filling  of  the  intestines 

^  Browm,  J.  Y.:  "Penetrating  and  Perforating  Gunshot  and  Stab  Wounds  of  the  Abdomen 
with  the  Report  of  Cases,"  Amer.  Jour.  Obstet.,  1903,  xhdii,  707. 

^  Brennfleck,  Ludwig:  "Bericht  iiber  Eine  durch  Shussverletzung  bedingte  Splenektomie," 
Miinch.  med.  Wochenschr.,  1903,  p.  803. 

^  DeWreden,  Romanovitsch:  "A  Consideration  of  the  Gunshot  Wounds  Inflicted  with  the 
Japanese  Small  Calibre  Bullets,"  Jour.  Assoc.  Med.  Surg.  U.  S.,  1906,  xviii,  311. 


654  PENETRATING    WOUNDS    OF   THE   ABDOMEN. 

and  bladder,  the  picture  changes  rapidly,  and  beginning  at  a  distance  of  four  hun- 
dred steps  the  explosive  effect  is  hardly  perceptible.  The  bullet  perforates  the 
stomach,  intestines,  and  bladder  in  the  shape  of  rapidly  closing  crevices.  Neither 
falling  out  nor  prolapsing  of  the  membrane  is  observed;  and  a  rapidly  developing 
adhesive  inflammation,  when  full  rest  is  maintained,  separates,  in  a  few  hours,  the 
injured  regions  from  the  rest  of  the  abdominal  cavity. 

Vaughn^  reports  a  series  of  14  cases  suffering  with  gunshot  wounds  of  the  peri- 
toneal cavity. 

8  cases  of  wound  of  small  intestine. 
6        "  "         large  " 

12  operated  on  in  from  one  to  twenty-eight  hours  after  injury. 
1         "         "    late. 
1  not  operated  on. 

9  patients  died — mortality  64%. 

Of  these,  six  died  from  hemorrhage,  one  from  peritonitis,  one  from  exhaustion,, 
and  one  from  shock. 

The  mortality  of  wounds  inflicted  by  the  small  missile  with  great  velocity  is  less 
than  that  of  wounds  inflicted  by  other  and  older  types  of  firearms.  Treves  stated 
that  only  40  per  cent,  of  gunshot  wounds  of  the  abdomen  in  the  Anglo-Boer  War, 
not  operated  on,  died;  but  it  has  been  well  said  (Hildebrandt)  that  if  those  who 
died  on  the  battlefield  were  included  as  well  as  those  dying  during  transportation,, 
the  mortality  would  exceed  70  per  cent. 

That  recovery  from  a  perforation  of  the  intestine  can  occur  without  operation 
is  unquestionably  true. 

Borden^  says  that  50  per  cent,  or  more  of  all  gunshot  wounds  of  the  abdomen 
received  in  war  penetrate  the  abdominal  cavity.  In  comparing  the  number  of  cases 
•of  penetrating  wounds  in  the  American  Civil  War,  where  45  per  cent,  were  penetrat- 
ing, with  those  of  the  Spanish-American  War,  where  63.9  per  cent.,  and  the  Phihp- 
pine  Insurrection,  where  64.4  per  cent,  were  penetrating,  it  will  be  seen  that  the 
number  of  penetrating  wounds  of  the  abdomen  has  probably  been  increased  by 
the  use  of  the  modern  small-cahber  bullets.  That  the  number  of  penetrating 
wounds  is  increased  is  to  be  expected  from  the  great  penetrating  power  of  the  modern 
missile.  It  will  be  noted  also  that,  while  the  cases  of  penetrating  wounds  are  in- 
creased, the  fatality  has  markedly  decreased.  In  the  case  of  the  English  troops  in 
the  Crimean  War,  92  per  cent,  of  penetrating  wounds  were  fatal,  and  in  the  Ameri- 
can Civil  War  90  per  cent,  succumbed.  It  is  stated  in  the  "Medical  and  Surgical 
History  of  the  War  of  the  Rebelhon"  that  not  a  single  case  of  wound  of  the  small 
intestine  recovered,  the  fifty-nine  recoveries  reported  being  from  wounds  of  the 
large  intestine.  In  the  Spanish-American  War  the  mortahty  was  66.6  per  cent., 
and  in  the  PhiHppine  Insurrection  66.4  per  cent.,  a  gain  of  a  Httle  over  20  per  cent, 
compared  with  the  American  Civil  War.     So  far  as  military  surgery  is  concerned, 

^Vaughn,  G.  T.:  "Gunshot  Wounds  of  the  Abdomen:  A  Review  of  Fourteen  Cases,  with 
Remarks  on  the  Mortality  and  Treatment,"  Jour.  Assoc,  of  Mil.  Surg.    1906,  xix,  150. 

^  Borden,  Major  William  C.:  "American  Practice  of  Surgery,"   Bryant  and  Buck,  ii,  727- 


ABSTRACT   OF    LITERATURE    OF    PENETRATING    WOUNDS    OF   ABDOMEN.        655 

it  appears  that  practically  all  the  saving  of  life  has  occurred  in  cases  not  operated 
on.  Colonel  Whitehead  reports  eight  cases  during  the  Tuah  campaign.  Of  these, 
five  were  operated  on  and  all  died.  The  other  three  did  not  require  operation  and 
recovered. 

In  the  Spanish-American  War  there  were  44  penetrating  wounds  of  the  abdomen 
in  the  regular  troops.  Of  these,  4  were  operated  upon  and  all  died.  In  the  40 
cases  not  operated  upon,  25  died,  a  mortality  of  62.5  per  cent.  In  1899  in  the  regu- 
lar and  volunteer  troops,  there  were  60  cases;  10  were  operated  upon  and  9  recovered. 
The  statistics  of  the  Anglo-Boer  War  and  the  Russo-Japanese  War  are  yet  un- 
available, but  the  operative  experience  in  these  wars  appears  to  have  been  about 
the  same  as  that  of  the  Spanish-American  War:  viz.,  that  practically  all 
of  the  cases  of  recovery  were  cases  which  did  not  come  to  operation.  In  civil 
life  statistics  relative  to  operative  interference  are  somewhat  more  favorable.  Oliver 
gives  22  cases  operated  upon;  of  these,  5  recovered  and  17  died,  or  22.8  per  cent, 
of  recoveries.  The  "Year  Book  of  Surgery,"  1901,  gives  66  recoveries  and  41  deaths 
in  107  cases  operated  on.  The  difference  in  the  mortality  in  the  operations  in  mili- 
tary and  civil  practice  is  sufficient  to  show  that  the  ability  to  operate  early  with 
aseptic  technic  and  adequate  surgical  appliances  and  assistance,  in  a  large  measure 
accounts  for  the  better  results  obtained.  In  considering  these  results  the  element 
of  time  is  of  major  importance.  Coley  gives  a  mortality,  from  cases  operated  upon 
in  the  first  twelve  hours,  of  53.9  per  cent.;  after  twelve  hours,  77.3  per  cent.  The 
relatively  greater  number  of  recoveries  in  the  first  twelve  hours  clearly  demonstrates 
the  importance  of  early  operation  in  these  cases.  The  sooner  an  operation  is  done 
after  the  receipt  of  the  injury,  the  less  likelihood  there  is  of  extravasation  of  intestinal 
and  stomach  contents  into  the  peritoneal  cavity,  with  resulting  infection  and  fatal 
peritonitis. 


CHAPTER  XL. 

HERNIA. 
By  Guy  L.  Huxxer,  M.D. 

Historical. — Operation  for  the  cure  of  reducible  hernia  was  performed  in  the 
days  of  the  Romans  by  methods  differing  but  shghtly  from  those  in  use  today. 
Celsus^  in  the  first  century  ad\'ised  an  incision  in  the  groin  extending  down  to  the 
hernia  sac,  exposure  of  the  field  of  operation  by  means  of  retractors,  and  the  freeing 
and  excision  of  the  sac,  preserving  the  testicle.  When  a  small  portion  of  omentum 
was  found  in  the  sac,  this  was  pushed  back  by  means  of  the  finger  or  a  sound,  while 
if  a  larger  portion  was  present  it  was  excised  by  means  of  caustics,  or  by  means  of 
the  ligature  and  scissors,  in  which  case  the  ends  of  the  ligature  were  brought  out  of 
the  wound.  If  the  contents  were  entirely  replaced  the  wound  was  closed  by  suture. 
Heliodorus'  gave  specific  directions  for  differentiating  the  infundibuliforum  fascia 
(called  by  him  the  dartos)  from  the  peritoneal  covering  of  the  sac,  and  for  t^visting 
and  cutting  off  the  sac. 

After  several  centuries  of  obli\-ion  the  operation  was  revived  in  the  middle  of  the 
seventh  century  by  Paul  of  .Egina,  who  directed  that  the  testicle  be  removed  with 
the  sac. 

It  is  remarkable  that  with  the  e^adence  of  surgical  acti^-ity  in  the  field  of  reducible 
hernia  during  the  early  centuries,  we  have  no  record  of  operations  for  strangulated 
hiernia.  Celsus  mentions  the  subject  only  to  sound  a  note  of  warning  against  the 
methods  in  use  in  his  day.  Not  imtil  the  sixteenth  century  do  we  find  records  of 
operation  for  strangulated  hernia,  which  up  to  that  time  had  been  treated  only  by 
taxis.  The  first  names  associated  with  the  operation  were  not  those  of  authoritative 
scholars,  but  of  empiricists  and  stone-cutters.  Florentinus  Vallensis  and  Maupas 
were  the  first  to  operate  successfully  for  strangulated  hernia,^  while  Pierre  Franco,* 
a  stone  and  rupture  cutter  of  Lausanne,  seems  to  have  been  the  first  to  comprehend 
the  subject  thoroughly;  and  he  described  both  the  extraperitoneal  and  intraperi- 
toneal methods  of  operating.  Evidences  of  Franco's  genius  as  a  surgeon  are  appar- 
ent in  his  directions  to  "make  a  generous  opening  into  the  peritoneum  without 
fear,"  and  to  replace  the  slippery  intestine  with  "a  little  piece  of  fine  linen."  He 
made  use  of  the  grooved  director  for  guiding  the  knife  when  cutting  the  ring.  In  suit- 
able cases  and  with  the  consent  of  the  patient,  after  freeing  the  strangulation  he 
proceeded  with  the  radical  cure  of  the  hernia,  "for,  indeed,  more  than  half  of  the 
necessary  interference  has  been  accomplished." 

^  Neuburger  u.  Pagel:  "Handbuch  der  Geschichte  der  Medizin,"  1905.  Bd.  iii.  S.  261. 
2  Albert:  "Lehrbuch  der  Chirurgie,"  Bd.  iii,  S.  282. 

^  Neuburger  u.  Pagel:  Loc.  cit.,  S.  267.  *  Neuburger  u.  Pagel:  Loc.  cit.,  S.  267. 

656 


HISTORICAL.  657 

Sir  Astley  Cooper  early  in  the  past  century  made  such  exhaustive  studies  in  the 
anatomy  and  pathology  of  hernia  that  there  has  been  but  little  of  importance  added 
since  his  writings. 

From  the  therapeutic  standpoint  success  in  the  surgical  treatment  of  hernia  can- 
not be  assured  without  aseptic  methods,  and  for  this  reason  the  almost  universal 
application  of  surgery  to  the  cure  of  ruptures  of  all  kinds  has  been  a  development  of 
our  own  generation.  In  the  evolution  of  the  modern  aseptic  operation  the  names 
most  familiar  to  the  surgical  world  are  those  of  Billroth  in  Austria,  Czerny  in  Ger- 
many, Lucas  Champonniere  in  France,  Bassini  in  Italy,  McEwen  and  Banks 
in  Great  Britain,  and  McBurney,  Andrews,  Ferguson,  Bloodgood,  and  Halsted  in 
America.  Many  other  names  from  both  continents  could  be  added  to  this  roll, 
names  of  surgeons  who  have  not  been  in  the  main  stream  of  controversy,  but  who 
have  made  substantial  contributions  toward  the  perfected  methods  of  our  day. 

It  is  surprising  that  hernia  literature  so  constantly  overlooks  the  work  of  Henry 
O.  Marcy,  of  Boston.^  So  far  as  I  can  learn,  Marcy  was  the  first  surgeon  of  modern 
times  deliberately  to  advise  and  undertake  the  radical  cure  of  a  reducible  hernia. 
On  February  4,  1878,  he  operated  on  a  woman  of  seventy  for  a  large,  direct  in- 
guinal hernia,  the  patient  having  been  successfully  operated  upon  by  Marcy  two 
months  previously  for  large  strangulated  hernia  of  the  opposite  side.^ 

His  first  radical  cure  of  strangulated  hernia  was  performed  in  1871.^  Marcy 
credits  his  teacher.  Lister,  with  having  performed  in  1869  the  first  recorded  opera- 
tion for  strangulated  hernia  done  under  the  new  antiseptic  method. 

Marcy 's  free  dissection  and  closure  of  the  parts  antedated  the  similar  operation 
done  by  Czerny,  of  Heidelberg,  in  October,  1877,  by  six  years.*  Czerny,  however, 
resected  the  hernia  sac  at  its  base,  while  Marcy  in  his  first  operations  returned  the 
sac  to  the  peritoneal  cavity. 

In  his  communication  to  the  International  Medical  Congress  held  in  London  in 
1881  he  "emphasized  the  freeing  of  the  sac  and  its  resection,  after  sewing  it  across 
at  its  base  with  a  continuous  animal  suture,  and  then  refreshing  the  pillars  of  the 
ring,  and  closing  by  deep,  buried,  double,  continuous  sutures  of  kangaroo  tendon, 
which  are  much  to  be  preferred  to  catgut." 

In  May,  1886,  at  the  annual  meeting  of  the  American  Medical  Association,'' 
Marcy  reported  a  series  of  over  thirty  consecutive  operations,  showing  that  with 
proper  antiseptic  precautions  the  operation  was  without  danger.  He  recommended 
the  dissection  of  the  sac  at  its  base,  its  suture,  and  excision,  the  restoration  of  the 
obliquity  of  the  canal,  and  closure  of  the  parts  with  the  buried  tendon  suture:  "(1) 
In  all  cases  of  operation  for  strangulation.  (2)  In  all  cases  where  the  abdominal 
contents  are  imperfectly  retained  by  the  truss,  unless  the  age  and  the  condition 

^  Marcy,  Henry  O.:  "The  Anatomy  and  Surgical  Treatment  of  Hernia,"  1892,  New- 
York. 

^  Marcy,  Henry  O.:  Trans.  Am.  Med.  Assoc,  1878,  vol.  xxix,  p.  295. 
^  Marcy,  Henry  O.:  Boston  Med.  and  Surg.  Jour.,  1871,  vol.  viii,  p.  315. 
*  Czerny:  Berlin,  klin.  Wochenschr.,  1881,  xviii,  45. 
^  Marcy,  Henry  O.:  Jour.  Am.  Med.  Assoc,  1887,  viii,  589. 
VOL.  II — 42 


658  HERNIA. 

of  the  patient  prevent.     (3)  In  the  large  class  of  children,  when  the  conditions  do  not 
promise  a  spontaneous  cure." 

Throughout  his  work  this  pioneer  was  a  most  ardent  and  consistent  experimenter 
in  search  of  a  durable  aseptic  animal  material  that  could  be  used  as  both  ligature  and 
suture.  He  advised  joining  like  tissues,  and  suturing  in  layers,  avoiding  the  lea^dng 
of  dead  spaces,  and  being  equally  careful  not  to  constrict  tissues.  Drainage,  in  his 
opinion,  was  not  only  needless  but  a  positive  disadvantage  and  danger.  In  his  last 
mentioned  communication,  however,  he  speaks  of  generally  using  a  twisted  horse- 
hair for  drainage,  and  in  his  London  report  he  says  that  drainage  is  used  if  the  ab- 
dominal wall  is  thick. 

Definition.— An  abdominal  hernia  is  an  abnormal  protrusion  of  the  parietal  peri- 
toneum occupied  temporarily  or  permanently  by  contents  from  the  abdominal 
cavity.  In  exceptional  cases,  as  in  hernia  of  the  retroperitoneal  organs,  the  peri- 
toneal sac  may  be  absent  or  it  may  only  partially  inclose  the  contents,  such  as  the 
ascending  or  descending  colon  or  the  bladder. 

The  coverings  of  a  hernia  differ  greatly  according  to  the  location  of  the  hernia 
and  to  the  conditions  of  its  origin  and  development.  In  the  development  of  a 
hernia  whatever  tissues  the  sac  pushes  ahead  of  it  become  the  coverings.  These 
coverings,  as  well  as  the  sac,  are  at  times  greatly  altered  by  such  forces  as  pressure, 
stretching,  traumatic  irritation,  and  inflammation. 

Contents. — Practically  every  organ  of  the  abdominal  cavity  has  been  found  oc- 
cupying a  hernial  sac.  We  naturally  find  most  frequently  these  organs  which  are 
more  movable,  viz.,  omentum,  small  intestine,  colon,  and  cecum.  The  cecum  with 
the  appendix  have  been  found  even  in  a  left  inguinal  hernia.  The  longest  mesentery 
is  that  supporting  the  ileum  at  a  point  about  25  cm.  above  the  ileocecal  valve,  hence 
the  predisposition  of  this  portion  of  the  bowel  to  become  herniated. 

Hernia  of  the  Bladder. — This  condition  is  rare.  Coley^  found  no  instance  of 
bladder  protrusion  in  950  cases  operated  upon  for  inguinal  and  femoral  hernia. 
This  viscus  is  most  often  found  in  the  direct  inguinal  hernia.  In  any  inguinal,  fem- 
oral, or  low  ventral  hernia  of  long  standing  and  large  size  the  bladder  should  be  kept 
in  mind  during  operation.  Hernia  of  the  bladder  may  be  developed  during^ opera- 
tion by  traction  on  the  hernia  sac  or  contents.  This  is  a  special  danger  in  operating 
upon  children,  and  one  must  here  watch  for  the  prevesical  fat  and  the  pecuhar  reti- 
form  bladder  musculature.  In  adults  with  long-standing  bladder  hernia  the  muscu- 
lature of  the  bladder  wall  may  be  wanting,  in  which  case  the  submucosa  closely 
resembles  a  second  hernia  sac.  A  careful  anamnesis  in  older  children  and  adults 
will  usually  lead  to  a  probable  diagnosis  which  may  be  verified  by  simple  methods  of 
examination.  The  bladder  is  generally  only  partially  prolapsed,  its  herniated  por- 
tion being  connected  with  the  abdominal  portion  by  an  isthmus.  The  patient  often 
passes  urine  in  two  stages,  and  sometimes  learns  to  compress  the  hernia  while 
voiding.  The  hernia  is  apt  to  be  tender,  and  pressure  over  it  causes  a  desire  to 
urinate.  The  tumor  decreases  in  size  upon  voiding,  and  a  forced  injection  of  water 
1  Coley:  "Abdominal  Hernia,"  Sultan,  1902,  p.  42. 


DEFINITION. 


659 


or  air  into  the  bladder  causes  the  hernia  to  augment  in  size.  Cystoscopic  examina- 
tion will  make  the  diagnosis  more  certain.  An  interesting  complication  is  the  forma- 
tion of  a  stone  in  the  herniated  portion  of  the  bladder. 

Hernia  of  the  Female  Genital  Organs. — The  ovaries  have  been  found  in  inguinal, 
femoral,  ventral,  umbilical,  obturator,  and  sciatic  hernias.     Both  ovaries  are  at  times 


Fig.  783. — Hernia  of  the  Pregnant  Uterus  in  a  Negress  (Kelly's  "Operative  Gynecology""). 
The  uterus  has  escaped  through  a  ventral  hernia,  due  to  a  celiotomy,  May  3,  1894,  of  which  the  scar  is  plainly 
seen.     The  patient  went  to  term  and  was  delivered  of  a  living  child  by  a  normal  labor.      (A.  R.,  Gyn.  No.  1390, 
Dec.  3,  1895.) 

found  in  bilateral  hernias.  A  Fallopian  tube  may  be  the  sole  occupant  of  a  hernia, 
but  it  is  more  often  found  in  association  with  the  ovary.  The  uterus  may  occupy 
a  hernia,  alone  or  with  its  adnexa,  and  in  this  position  it  may  become  pregnant 
(Fig.  783).  R.  Birnbaum^  reports  a  case  of  inguinal  hernia  of  the  uterus  and 
1  Birnbaum,  R.:  Berlin,  klin.  Wochenschr.,  1905,  vol.  xlii,  S.  632. 


660  HERNIA. 

finds  the  report  of  twenty-three  cases  in  the  Hterature.  Andrews^  gives  the  following 
table  of  recorded  cases  of  hernia  of  the  female  peMc  organs,  including  four  cases  of 
liis  own : 

Cases. 

Hernia  of  tube  without  ovary 46 

"        "  ovary  and  tube 80 

"        "  ovary  without  tube  (or  tube  not  mentioned) 167 

"        "  non-gravid  uterus 43 

"        "  pregnant  uterus 30 

Total 366 

Hernia  of  the  ovarv  is  usually  congenital  and  is  often  associated  with  other 
malformations.    The  signs  and  symptoms  of  hernia  of  the  ovary  are  usually  typical, 


l^cl. 


Fig.  784. — Partial  Hernia  of  the  Left  Ovary  (Kelly's  "Operative  Gynecology")- 

The  short  tube  close  by,  lying  over  the  superior  strait,  has  no  uterine  connection.     The  uterus  is  displaced  markedly 

to  the  right  side.     The  right  ovary  and  tube  are  normal.     Nov.  1,  1897. 

but  the  presence  of  other  organs  in  the  hernial  sac  may  so  mask  the  picture  that  a 
diagnosis  is  impossible.  The  hernia  contains  a  rounded  or  oval  body,  usually  of 
firm  consistence,  and  quite  freely  movable.  Pain,  of  the  peculiar,  sickening,  ovarian 
type,  is  caused  by  pressure,  and  a  truss  cannot  be  worn.  The  pain  and  tenderness 
are  generally  more  marked  during  the  menstrual  epoch.  A  small  inguinal  swelling 
present  from  infancy  suddenly  gets  larger  at  puberty  and  shows  the  above  signs 
and  symptoms,  particularly  if  the  tumor  be  bilateral.  Malformations  of  the 
external  genitalia,  congenital  absence  of  the  uterus,  displacement  of  the  uterus, 
^  Andrews:  Jour.  Am.  iled.  Assoc,  1905,  xlv,  1625. 


ETIOLOGY. 


661 


upward  if  the  inguinal  swelling  be  bilateral,  or  to  the  corresponding  side  if  mono- 
lateral,  are  all  signs  of  importance.  Fig.  784  shows  an  exception  to  this  rule  of 
displacement.  Absence  of  one  or  both  ovaries  on  bimanual  examination  of  the 
pelvis  is  to  be  expected.  Movement  of  the  uterus  through  the  vagina  or  rectum 
or  traction  on  the  cervix  with  a  tenaculum  will  displace  the  hernial  contents. 

The  stomach  has  been  found  in  umbihcal,  diaphragmatic,  inguinal,  and  femoral 
hernias.  Coexistence  of  hernia  and  severe  gastric  symptoms  is  not  necessarily  an 
indication  of  their  direct  relation ;  on  the  contrary,  we  now  know  that  the  gastric 
symptoms  are  usually  reflex  and  due  to  traction  on  the  parietal  peritoneum  about 
the  hernial  orifice. 

Naturally  the  less  movable  abdominal  organs  are  but  rarely  found  in  a  hernia. 
The  liver,  alone  or  with  other  organs, 

is   found   in    diaphragmatic   and   con-  \ 

genital  umbilical  hernia.  Bullard  ^  re- 
ports a  case  of  congenital  hernia  of  the 
liver  into  the  umbilical  cord  and  col- 
lects one  hundred  and  twenty-eight 
cases  from  the  literature.  Other  organs 
which  have  been  described  in  hernias 
are  the  gall-bladder,  kidney,  ureter, 
spleen,  and  pancreas. 

Etiology. — Hernia  is  either  con- 
genital or  acquired.  The  first  year  of 
life  is  marked  by  the  greatest  number 
of  hernias.  Many  of  these  are  present 
at  birth,  while  the  majority  appear 
later.  It  is  probable  that  practically 
all  hernias  of  early  life  have  a  con- 
genital sac  (Figs.  785,  786,  787),  al- 
though the  contents  may  not  descend 
until   other  factors  become  dominant. 

Authors  generally  agree  that  nearly  all  (some  say  all)  true  hernias  are  of  gradual 
formation,  i.  e.,  that  the  sac  is  congenitally  present  or  gradually  formed  after 
birth,  and  that  the  contents  appear  because  of  a  sudden  injury,  or  because  of 
forces  acting  over  a  long  period  of  time. 

In  acquired  hernia  we  recognize  anatomic  causes  and  immediate  exciting 
causes.  Anatomically  all  the  openings  from  the  abdominal  cavity  for  the  passage 
of  vessels,  nerves,  or  other  organs,  are  points  of  weakness.  Weak  areas  follow  surgi- 
cal wounds  if  there  is  bad  closure,  suppuration,  or  drainage.  ]Mobility  of  the  ab- 
dominal organs  and  intra-abdominal  tension  are  anatomic  and  physical  conditions  of 
moment.  Of  the  immediate  exciting  causes  the  most  important  are  sudden,  violent 
exertion,  gradual  pressure  from  heavy  lifting,  certain  pathologic  conditions,  and 

1  Bullard:  Amer.  Med.,  1902,  iv,  742. 


Fig.  785. — Showing  Descent  of  the  Testicle  (Stieda- 

Pausch). 
Position  of    the  testicle   at  about  the  fourth  month  of 

fetal  life. 


662 


HERNIA. 


communis 


propria 


Fig.  786. — Showixg  Descent  of  the  Testicle  (Stieda- 
Pausch). 
Position  of   the    testicle   in  the  ninth  month  of   fetal 
life;    origin  of  the  vaginal  process  of  the  peritoneum  which 
remains  as  the  hernia  sac  in  cases  of  congenital  origin. 


pregnancy.     A  pathologic  condition  not  sufficiently  recognized  is  the  poor  general 
tone  of  the  muscles  and  tissues  due  to  sedentary  habits,  to  old  age,  or  follomng 

illness,  particularly  gastro-enteritis  in 
children.  The  frequency  of  hernia 
in  multipara  is  referred  to  the  re- 
peated stretching  and  relaxation  of 
the  abdominal  walls  incident  to  preg- 
nancy. 

Diagnosis. — Generally  speaking, 
the  diagnosis  of  an  abdominal  hernia 
is  not  difficult,  but  there  are  cases 
in  which  a  certain  diagnosis  cannot 
be  made  even  with  the  most  careful 
and  systematic  attention  to  all  the 
signs  and  symptoms.  The  methods 
of  establishing  a  diagnosis  for  all 
varieties  of  hernia  will  be  discussed 
under  the  special  section  on  inguinal 
hernia. 

Accidents  and  Complications  of 
Hernia. — Among  the  more  common 
and  dangerous  complications  to  which 
the  hernia  patient  is  subject  may  be  mxcntioned  inflammation,  irreducibility,  and 
strangulation. 

Inflammation. — The  anatomic 
conditions  of  most  hernias  are 
such  as  to  favor  inflammatory 
changes  during  some  period  of 
their  history.  The  narrow  neck 
and  wider  sac  favor  conditions  of 
stasis  and  consequent  inflamma- 
tory reaction  in  the  sensitive  peri- 
toneum of  both  the  sac  and  the 
abdominal  contents.  The  super- 
ficial location  exposes  the  sac  and 
its  contents  to  external  ^^olence, 
and  the  pressure  of  a  truss  may 
prove  a  source  of  irritation. 
Every  grade  of  inflammation  is 
possible.  At  times  the  process  is 
so  mild  and  chronic  that  the 
hernial  contents  become  adherent  without  special  symptoms,  some  hernias  under- 
going spontaneous  cure  through  the  process  of  chronic  inflammation.     The  pres- 


Funicul.  spermdf. 


Tlinica.  yag-i'mL 
communis 


Turn 
propria. 


Fig.  787. — Showing  Descent  of  the  Testicle  (Stieda-Pausch). 

Position  of  the  testicle  at   birth;   origin  of  the  tunica  vaginalis 

propria. 


ACCIDENTS    AND    COMPLICATIONS    OF   HERNIA.  663 

ence  of  a  truss  probably  acts  favorably  in  some  instances  by  holding  back  the 
abdominal  contents  and  so  irritating  the  neck  of  the  sac  as  to  excite  a  chronic  in- 
flammation which  ultimately  results  in  adhesions  and  occlusion.  In  other  cases 
the  omentum  forms  a  plug  which  becomes  adherent  in  and  closes  the  neck  of 
the  sac.  At  times  the  inflammation  occurs  in  mild  acute  attacks  in  which  the 
patient  suffers  pain  and  tenderness  in  the  hernia  region.  Such  attacks  may 
follow  unusual  exertion  which  brings  about  circulatory  changes  within  the  sac, 
or  causes  increased  irritation  by  the  truss;  or  they  follow  a  kick  or  other  external 
violence. 

Irreducihility .- — The  mild  acute  attacks  of  inflammation  usually  subside  without 
special  treatment  and  with  no  discoverable  gross  changes  in  the  hernia,  but,  as  with 
the  mild  chronic  inflammatory  changes  just  mentioned,  permanent  adhesions  may 
form  and  lead  to  the  irreducihility  of  a  formerly  reducible  hernia.  Another  con- 
dition preventing  the  reduction  of  hernial  contents  is  a  development  of  a  dispro- 
portion between  the  neck  of  the  sac  and  the  volume  of  its  contents.  This  factor  is 
often  dependent  upon  inflammation,  which  causes  adhesions  between  the  hernial 
contents  and  forms  a  mass  too  large  to  be  returned.  In  such  cases  there  may 
be  no  adhesions  to  the  sac  wall.  The  omentum  is  the  organ  which  most  frequently 
becomes  irreducible.  This  may  occur  because  of  inflammatory  adhesions  binding  it 
to  the  fundus  or  to  the  neck  of  the  sac,  or  a  disproportion  may  arise  between  the  size 
of  the  hernial  ring  and  the  contained  omentum.  A  section  of  omentum  may  occupy 
a  hernial  sac  for  years  and  be  perfectly  reducible,  when  a  slight  inflammatory  swell- 
ing or  other  change  causes  the  neck  of  the  sac  to  become  so  small  that  the  omentum 
cannot  be  replaced.  The  weight  and  dragging  of  the  omentum  may  cause  a  dwin- 
dling of  the  portion  in  the  neck  of  the  sac.  Any  pressure  at  the  hernial  ring  tends 
first  to  shut  off  the  venous  flow  and  cause  an  acute  or  chronic  passive  congestion, 
thus  increasing  the  bulk  of  the  hernial  contents.  The  natural  increase  in  size  of  the 
omentum  incident  to  advanced  life  often  interferes  with  its  reduction.  The  similar 
increase  in  size  of  the  epiploic  appendages  has  been  found  to  cause  irreducihility 
in  cases  of  hernia  of  the  large  bowel.  Tumors  of  the  mesentery  have  caused  the 
same  result.  Hernia  rarely  become  irreducible  before  adult  life.  The  condition 
is  said  to  be  transitory,  seldom  lasting  through  an  entire  lifetime.  For  this  reason 
]\Iacready  advised  the  application  of  pressure  by  means  of  a  properly  adjusted  truss. 
Femoral  hernias  are  more  difficult  of  reduction  than  inguinal.  Several  years 
are  sometimes  required  for  the  reduction  by  pressure.  Too  often  the  conditions  of 
inflammation  and  irreducihility  interact  and  cause  strangulation. 

Strancfulation  of  a  hernia  is  that  condition  which  results  when  the  compression  in 
the  hernial  ring  or  at  the  mouth  of  the  sac  is  such  as  to  entrap  the  hernial  contents  and 
cause  stasis  of  its  circulation.  The  strangulation  may  be  temporary  and  by  proper 
measures  quickly  relieved.  But  if  unheeded,  the  tendency  is  toward  progressively 
serious  and  fatal  results.  The  rapidity  and  seriousness  of  the  process  depend  in  a 
measure  upon  the  hernial  contents,  but  no  rule  can  be  formulated ;  for  an  intestinal 
strangulation  may  extend  over  a  period  of  several  days  without  serious  injury  to  the 


664  HERNIA, 

bowel,  while  an  omental  strangulation  may  rapidly  lead  to  infarct,  necrosis,  infec- 
tion, and  death. 

There  are  many  theories  as  to  the  mechanism  of  strangulation.  Referring  the 
student  to  special  works  on  hernia  for  these  theories,  we  will  speak  of  two  generally 
accepted  views  as  to  the  mode  of  origin. 

Elastic  Strancjidation. — When  from  any  cause  a  loop  of  intestine  or  other  viscus 
is  forced  into  the  hernia  sac  and  the  momentarily  dilated  orifice  resumes  its  usual 
dimensions,  the  hernial  contents  are  subjected  to  pressure  at  the  neck  of  the  sac 
and  strangulation  follows. 

Fecal  Strangulation. — If  from  sudden  augmentation  of  the  intra-abdominal  pres- 
sure or  from  other  cause  the  fecal  contents  of  the  herniated  loop  of  intestine  be 
suddenly  increased,  there  may  result  a  disproportion  between  the  neck  of  the  sac 
and  the  hernial  contents. 

In  either  of  the  two  modes  the  results  are  the  same :  there  is  unusual  pressure  at 
the  neck  of  the  sac.  This  may  be  so  great  as  to  cause  complete  stasis  of  circu- 
lation and  anemic  infarct  of  the  hernial  contents.  Usually,  however,  there  is  at 
first  venous  stasis.  This  leads  to  increase  in  bulk  of  the  hernial  contents,  transu- 
dation of  serum,  necrosis  of  the  tissues,  and,  if  the  contents  be  intestine,  perforation 
follows.  Infection  takes  place  probably  through  the  general  circulation  if  the 
incarceration  be  of  the  omentum,  and  through  the  intestinal  walls  if  intestine  be 
present.  The  inflammation  now  spreads  to  the  surrounding  tissues.  The  phleg- 
mon may  rupture  externally,  in  which  case  spontaneous  cure  may  result  if  only  the 
omentum  be  present,  or  a  fecal  fistula  may  follow  intestinal  necrosis.  If  the  in- 
flammation extends  to  the  abdominal  cavity,  septic  peritonitis  and  death  is  the  usual 
result. 

Symptoms  and  Course  of  Intestinal  Strangulation. — The  most  common  symptom 
of  intestinal  strangulation  is  pain.  The  patient  is  usually  able  to  state  just  the  time 
of  onset  and  its  immediate  cause,  usually  a  hearty  laugh,  a  cough,  or  some  unusual 
violent  muscular  effort.  There  is  at  first  a  sharp  pain  in  the  region  of  the  hernia 
orifice,  and  the  patient  finds  a  swelling  for  the  first  time,  or  he  is  unable  to  return  a 
formerly  reducible  hernia.  Nausea,  eructation,  and  vomiting  quickly  supervene, 
and  the  vomited  material  comes  successively  from  the  stomach  and  the  intestines, 
finally  becoming  fecal  if  the  obstruction  be  low  in  the  tract.  Twisting  or  griping 
pain  from  the  peristalsis  causes  great  restlessness  and  agitation.  Neither  feces  nor 
gas  are  passed  by  the  rectum,  although  enemata  may  wash  out  some  fecal  material 
located  below  the  constriction.  Too  much  dependence,  however,  should  not  be 
placed  upon  the  bow^el  symptoms.  At  times  there  is  nausea  without  vomiting. 
And  again  cathartics  and  enemata  may  bring  away  considerable  fecal  material. 
The  local  inflammation  may  result  in  a  diarrhea  and  passage  of  large  quantities  of 
mucus  and  feces. 

Locally  the  hernia,  which  is  at  first  soft,  soon  becomes  tense  and  extremely 
painful  on  manipulation.  Edematous  swelling  of  its  contents,  accumulation  of 
fluid,  both  inside  and  without  the  affected  loop,  and  the  accumulation  of  gases 


RARE    COMPLICATIONS. 


665 


contribute  to  the  hardness.  The  hernial  sweUing  now  becomes  discolored  and  ex- 
tremely sensitive  to  the  touch.  The  external  wall  may  perforate  and  give  rise  to  a 
fecal  fistula  or  anus  preternaturalis.  Or  if  the  inflammation  extends  to  the  peri- 
toneal surface,  the  patient  rapidly  becomes  worse.  The  pain  increases  with  the 
first  wave  of  peritoneal  infection,  after  which  it  may  disappear.  Nausea  and 
vomiting  often  become  worse,  the  patient  is  cyanotic,  the  pulse  grows  small  and 
its  rate  increases,  the  temperature  may  rise  or  it  may  fall  below  normal,  the  tongue 
becomes  coated  and  dry,  the  eyes  retract,  the  nose  is  pointed,  and  a  cold  sweat 
covers  the  entire  body.  The  urinary  secretion  is  diminished  and  anuria  may  be 
the  direct  cause  of  death.  Graser  says  that  95  per  cent,  of  untreated  strangulated 
intestinal  hernias  end  in  death.  Berger^  states  that,  per  hundred  cases,  stran- 
gulation is  about  twice  as  frequent  in  the  female  as  in  the  male.  This  is  probably 
due  to  the  preponderance  of  femoral  hernias  in  the  female  and  the  greater  liability 
of  this  form  to  strangulation.  Strangulation  is  rare  in  children  and  treatment  by 
taxis  is  usually  successful. 

Special  mention  must 
be  made  of  strangulated 
hernia  of  the  intestinal 
wall  in  which  only  a  por- 
tion of  an  intestinal  seg- 
ment protrudes  through 
the  hernial  neck  (Fig.  788). 
The  portion  strangulated 
may  pass  through  the 
same  phases  of  degener- 
ation as  in  the  strangula- 
tion of  an  entire  loop,  and, 
like  the  latter,  may  end  in 

external  perforation  and  fecal  fistula,  or  in  general  peritonitis.  The  symptoms  are 
very  similar:  there  is  sudden  severe  pain  with  nausea  and  vomiting.  The  intestine 
may  be  open  and  respond  to  cathartics  and  enemata  or  there  may  be  obstruction. 
Diarrhea  may  prevail.  The  physical  signs  often  prove  the  physician's  hete  noir. 
If  the  sac  contents  consist  only  of  the  portion  of  intestinal  wall,  the  hernia  is  of 
necessity  very  small.  Careful  examination  should  be  made  of  the  femoral  and 
obturator  regions,  for  it  is  here  that  this  class  of  hernias  occur  most  frequently. 
Tenderness  and  even  redness  may  be  found  when  no  tumor  is  discoverable. 

Rare  Complications. — Among  other  unpleasant  complications  of  hernia  should 
be  mentioned  an  inflammation  of  a  contained  vermiform  appejidix,  in  which  the 
symptoms  are  likely  to  lead  to  a  diagnosis  of  strangulated  hernia.  This  condition 
occurs  most  frequently  in  children  (21  per  cent,  in  children  under  two  years  of  age — 
Priiss  ^)  and  in  the  aged. 


Fig.  788. 


A  Strangulated  Hernia  of  the  Intestinal  Wall  (after 
Sultan). 
Showing  only  moderate  degree  of  tissue  change. 


^  Berger:    "Rfeultats  de  I'examens  de  dix  mille  observations  de  hernies,"  etc.,  Paris,  1896. 
^  Pruss:  Inaug.  Dis.  Halle- Wittenberg,  1902. 


^55  HERNIA, 

Tuberculosis  of  the  hernia  sac  is  rare.  R.  Lewisohn^  reports  fifty-eight  cases  from 
the  literature  and  adds  four  cases  of  his  own.  It  may  arise  in  the  sac  or  be  secon- 
dary to  a  general  peritoneal  or  miliary  tuberculosis. 

Carcinoma  of  the  hernial  contents  has  been  described,  and  the  following  local 
signs  may  be  very  similar  in  the  last  two  diseases :  spontaneous  pain,  enlargement 
and  hardening  of  the  sac,  dulling  of  the  percussion  note,  fluid  in  the  sac  which 
may  return  to  the  abdominal  cavity  on  pressure. 

Certain  complications  are  associated  with  treatment  or  operation  for  hernia. 

Severe  intestinal  hemorrhage  at  times  follows  the  reduction  of  a  strangulated 
hernia,  probably  due  to  sloughing  of  the  mucosa.  Stricture  following  this  same 
process  not  infrequently  causes  intestinal  obstruction  at  a  later  period  (Meyer'). 

Inflammation  of  the  omentum  sometimes  follows  operation  for  strangulated  hernia. 
Soon  after  the  operation  a  hard  abdominal  tumor  is  palpated  which  may  slowly 
disappear  or  eventually  break  down  in  suppuration. 

Pneumonia  is  not  an  uncommon  comphcation  of  hernia  operation,  particularly 
after  operation  upon  strangulated  hernia;  and  this  accident  seems  to  occur  as  fre- 
quently after  operations  under  local  anesthesia  as  after  those  for  which  general  anes- 
thesia has  been  used.  This  makes  probable  the  generally  accepted  view  that  these 
pneumonias  arise  from  the  deposition  in  the  lungs  of  infected  thrombi  from  the 
mesentery  of  the  strangulated  gut. 

Recurrence  after  operation  will  naturally  depend  somewhat  upon  the  operator 
and  upon  the  method  employed;  but  with  any  of  the  better  methods  in  use  the  after- 
results  depend  upon  various  important  factors.  The  character  of  the  tissues, 
whether  flabby  or  of  good  tone,  is  a  very  important  element  in  the  final  result.  Per 
primam  healing  of  the  wound  is  important.  Bloodgood  ^  shows  that  in  Halsted's 
chnic  there  were  but  3  per  cent,  of  returns  in  hernia  cases  healing  per  primam, 
while  in  suppurating  cases  there  were  about  20  per  cent,  of  returns. 

GENERAL  TREATMENT  OF  HERNIA. 

We  have  stated  that  the  most  prolific  hernia  period  is  the  first  year  of  life;  and 
the  practitioner  should  remember  that  many  hernias  undergo  spontaneous  cure. 
The  post-natal  closure  of  the  peritoneal  diverticulum  may  be  complete  and  result  in 
permanent  cure,  or  there  may  be  simply  a  narrowing  of  the  neck  of  the  canal;  and 
in  after  years,  with  favoring  conditions,  the  hernia  will  again  appear. 

Treatment  by  Truss. — Under  the  section  on  Hernia  Complications  we  have 
spoken  of  the  value  of  the  truss  in  some  cases,  and  we  drew  attention  to  the  fact 
that  the  danger  of  strangulation  is  not  so  great  in  children  as  in  adults.  By  the 
use  of  a  proper  truss  or  bandage  there  is  considerable  chance  for  cure  of  an  umbilical 

1  Lewisohn,  R.:  Mitteil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1903,  Bd.  xi,  Heft  5,  S.  657. 

^  Meyer:  "Intestinal  Stenosis  after  Operation  or  Non-operative  Reposition  of  Incarcerated 
Hernia,"  Deutsche  Zeitschr.  f.  Chir.,  Leipzig,  1905,  Ixxvi,  S.  297. 

3  Bloodgood:  "Operations  on  459  Cases  of  Hernia  in  the  Johns  Hopkins  Hospital  from  June 
1889,  to  January,  1899,"  Johns  Hopkins  Hosp.  Rep.,  1898,  vii,  p.  223. 


GENERAL    TREATMENT    OF    HERNIA.  667 

or  inguinal  hernia  in  children.  If  operation  becomes  necessary  it  is  more  exact  and 
the  after-care  more  efficient  after  the  second  year.  Referring  the  student  for  his 
knowledge  of  trusses  to  special  works  on  hernia,  we  herewith  present  Sultan's  general 
rules  for  their  application:  "  (1)  The  hernia  must  be  reduced  before  the  application 
of  the  truss.  (2)  The  pad  must  always  be  placed  in  direct  contact  with  the  skin 
or  upon  a  small  piece  of  linen.  (3)  The  pressure  of  the  pad  must  never  be  so  great 
as  to  injure  the  skin;  cutaneous  excoriation  may  frequently  be  prevented  by 
scrupulous  cleanliness  of  the  hernial  region  and  by  repeated  bathing  with  alcohol. 
(4)  When  the  truss  has  been  applied,  be  sure  that  it  retains  the  hernia  when  the 
patient  walks,  sits,  lies  down,  goes  upstairs,  bends  backward  and  forward,  and 
coughs.  (5)  In  children  the  chances  of  recovery  are  more  favorable  the  earlier  the 
treatment  with  the  truss  is  commenced.  A  truss  may  ordinarily  be  applied  when  the 
child  is  three  or  four  months  old.  In  these  cases  a  washable  pad  of  hard  rubber 
is  to  be  recommended." 

Treatment  by  Injections. — Since  Schwalbe  in  1877  first  introduced  the  treat- 
ment by  injections  of  70  per  cent,  alcohol,  this  and  similar  injection  methods  have 
not  found  great  favor  with  the  profession  at  large.  The  injections  are  made  about 
the  lieck  of  the  sac  with  some  irritating  fluid  for  the  purpose  of  causing  a  closure 
of  the  sac  by  inflammatory  adhesions.  Naturally  the  method  is  most  successful  in 
young  children,  but  it  is  not  without  its  dangers,  it  usually  fails  to  cure,  and  in  case 
of  future  operation  there  are  serious  complicating  adhesions. 

Treatment  by  Operation. — Recent  statistics  from  the  larger  cHnics  covering 
the  period  since  hernia  operations  reached  a  liigh  degree  of  perfection  show  that  we 
can  now  give  a  patient  desiring  an  operation  a  very  definite  and  good  prognosis. 
The  desire  of  a  patient  to  be  rid  of  his  hernia  is  now  considered  sufficient  indication 
for  operation,  except  in  special  cases.  Sultan's  table  of  5419  cases  collected  during 
the  period  of  1895  to  1900  shows  a  death-rate  of  0.5  per  cent,  and  recurrence  ranging 
from  1.2  per  cent,  to  11.9  per  cent.  This  means  that  the  average  patient  with  an  un- 
complicated hernia  may  submit  to  the  operation  at  the  hands  of  an  experienced 
surgeon  with  almost  no  danger  to  his  life  and  with  an  overwhelming  chance  for  com- 
plete recovery.  The  classes  in  which  operation  may  be  questioned  are  the  very 
young,  the  very  old,  and  patients  with  hernias  of  enormous  size.  The  reasons  for 
non-operative  treatment  in  very  young  children  have  been  cited.  In  the  case 
of  the  aged  the  question  of  operating  must  be  considered  in  relation  to  the  degree  of 
trouble  caused  by  the  hernia  and  with  reference  to  the  condition  of  the  lungs  and 
vascular  system.  Since  the  more  general  use  of  local  anesthesia  methods  the  field  of 
operative  relief  for  the  aged  has  widened  greatly. 

Treatment  of  Hernia  Complications. — As  already  stated  there  are  many  minor 
attacks  of  pain,  probably  indicating  an  inflammatory  reaction,  which  subside 
without  treatment.  ]\Iore  pronounced  or  persistent  attacks,  however,  should  be 
combated  by  rest  in  bed,  ice-caps,  or  other  counterirritants,  and  attention  to  the 
bowels. 

Irreducible  hernia,  if  it  represent  a  chronic  state  without  evidence  of  stran- 


668  HERNIA. 

gulation,  may  be  successfully  treated  by  long-continued  pressure,  as  from  a  well- 
fitting  truss.  Cases  which  have  recently  become  irreducible  may  be  treated  by 
several  methods.  Rest  in  bed  may  so  change  the  circulatory  conditions  as  to  render 
reduction  easy.  Ice-bags  or  hot  cloths,  repeatedly  applied,  are  often  of  value. 
Taking  advantage  of  posture  may  be  effectual.  The  Trendelenburg  or  the  knee- 
elbow  or  knee-chest  positions  may,  by  dragging  from  within,  cause  a  reduction  of  the 
sac  contents.  Taxis  is  the  most  valuable  non-operative  remedy,  and  this  is  used 
alone  or  in  association  with  the  above-mentioned  measures.  Patients  with  hernias 
difficult  of  reduction  often  learn  the  most  favorable  posture  and  the  most  effectual 
method  of  taxis. 

Strangulated  hernia  generally  calls  for  prompt  operative  interference.  If  seen 
early,  or  if  the  symptoms  are  mild,  the  above  palliative  measures  may  be  adopted 
in  an  attempt  at  reduction.  Taxis  should  not  be  used  if  there  is  evidence  of  tissue 
changes  or  infection  in  the  sac.  Unless  one  has  seen  many  cases  and  can  form 
a  fair  estimate  of  the  real  condition  of  the  patient  and  of  the  local  changes,  steps 
should  be  taken  at  once  to  place  the  patient  in  the  most  favorable  condition  for  an 
operation.  The  loss  of  a  few  hours  may  determine  the  patient's  death.  Taxis  may 
cause  great  injury  and  even  perforation  of  an  already  weakened  bowel;  it  may 
result  in  a  reduction  en  masse,  that  is,  in  the  reduction  of  the  sac  contents,  together 
with  the  constricting  neck  of  the  sac.  The  contents  may  be  reduced  but  an  in- 
testinal obstruction  persist  because  of  a  volvulus  or  an  angulation  from  adhesions; 
or  the  reduction  of  infected  sac  contents,  or  a  gangrenous  bowel,  may  result  in  sub- 
sequent fatal  general  peritonitis.  If  taxis  be  performed,  it  should  be  done  with 
great  care.  The  left  hand  firmly  grasps  the  region  of  the  neck  of  the  sac,  while  the 
right  hand  spreads  its  compression  broadly  over  the  entire  hernial  tumor  with  move- 
ments which  tend  to  draw  the  contents  away  from  the  abdominal  wall.  The 
effort  is  to  straighten  the  sharply  angled  intestine  and  thus  favor  the  escape  of  some 
of  its  contents  and  a  lessening  of  its  distention.  Rules  as  to  the  length  of  time 
taxis  may  be  performed  are  of  little  value,  as  it  is  evident  that  one  surgeon  will 
accomplish  more  good  or  evil  in  five  minutes  than  another  would  in  a  half  hour. 

Relaxation  of  the  tense  hernial  ring  may  be  gained  by  anesthesia,  but  taxis 
should  not  be  performed  under  these  conditions  without  first  gaining  the  patient's 
consent  for  operation  and  being  ready  to  proceed  with  herniotomy  under  the  same 
anesthesia  in  case  taxis  fails.  In  no  case  of  suspected  strangulation  should  cathar- 
tics be  given  by  mouth.  Enemata  may  be  given,  although  they  will  seldom  give 
more  than  temporary  relief  if  the  case  is  one  of  strangulation.  If  vomiting  has 
begun,  stomach  lavage  may  afford  temporary  relief.  It  should  be  used  before  a 
general  anesthesia,  and  again  just  before  the  patient  recovers  from  anesthesia. 
Salts,  oil,  or  calomel  left  in  the  stomach  after  the  post-operative  lavage  is  a  procedure 
to  be  determined  by  the  condition  of  the  bowel.  If  the  bowel  is  in  a  questionable 
state  at  the  time  of  operation,  or  if  it  is  reduced  by  taxis,  it  is  wiser  to  avoid  peri- 
staltic excitement  for  some  hours  or  even  days  after  the  operative  reduction.  If  the 
hernial  contents  have  been  completely  reduced  by  taxis,  a  pad  of  gauze,  or,  if  there 


GENERAL    TREATMENT    OF   HERNIA.  669 

is  no  tenderness,  a  truss,  should  be  at  once  applied  to  prevent  another  descent  and 
consequent  strangulation.  After  a  reduction  by  taxis  the  patient  should  be  most 
carefully  watched  for  at  least  forty-eight  hours  because  of  the  serious  dangers  al- 
ready mentioned.  If  taxis  fails,  or  if  for  any  reason  taxis  is  contraindicated,  opera- 
tion should  be  performed  at  once. 

The  operative  procedure  for  strangulated  hernia  may  be  simple — the  cutting 
of  the  hernial  ring,  and  the  reduction  of  the  contents  with  the  apphcation  of  a  binder; 
or  it  may  prove  most  difficult,  requiring  the  exposure  of  the  hernial  sac,  the  freeing  of 
many  adhesions,  and  a  resection  of  the  bowel.  Between  the  conditions  caUing  for 
these  two  extremes  of  operative  treatment  is  a  wide  range  of  possibilities,  requiring 
the  greatest  exercise  of  surgical  skill,  and  particularly  of  surgical  judgment.  The  sur- 
geon must  determine  from  the  history  of  the  attack  and  from  the  macroscopic 
appearances  the  degree  of  tissue  injury  and  the  probabilities  of  their  restitutio  ad 
integrum.  From  the  appearance  of  the  sac  contents,  and  possibly  with  microscopic 
aid,  he  must  ascertain  whether  infection  is  present,  estimate  its  degree  and  virulence, 
and  decide  whether  the  peritoneum  and  other  tissues  will  successfully  combat 
the  condition.  He  must  carefully  weigh  the  signs  and  symptoms,  compute  the 
degree  of  shock  already  suffered,  and  have  a  fair  idea  of  the  patient's  reserve  powers. 

If  the  patient  is  in  good  condition  he  may  be  given  a  bath  and  the  usual  skin 
preparation.  If  food  has  been  taken  recently,  the  stomach  may  be  washed  out  with 
the  tube  before  anesthesia.  If  there  is  any  question  about  the  heart  or  lung  con- 
dition, or  if  there  be  marked  shock,  local  infiltration  anesthesia  is  preferable.  Obese 
women  with  large  ventral  hernias  are  not  infrequently  the  subjects  of  strangulation, 
and  general  anesthesia  should  never  be  risked  in  this  class  of  cases  because  of  the 
danger  of  fatty  heart,  strangulation  from  vomiting,  and  the  more  remote  danger  of 
pneumonia.  The  principal  points  of  the  operation  are:  (1)  to  cut  down  upon  the 
sac;  (2)  to  examine  the  contents;  (3)  to  cut  the  neck  of  the  sac;  (4)  to  return  the 
contents  if  their  condition  permits;  (5)  to  perform  a  radical  cure  of  the  hernia. 
The  radical  cure  should  be  attempted  in  but  a  limited  number  of  cases— those, 
namely,  which  have  had  .a  thorough  skin  preparation  and  in  which  the  changes  in 
the  sac  contents  do  not  jeopardize  the  heahng  of  the  wound.  In  exposing  the 
sac  the  skin  incision  is  carried  well  above  the  ring  in  order  that  the  seat  of  constriction 
may  be  freely  inspected.  If  the  strangulation  be  of  a  large  ventral  hernia,  great 
care  must  be  exercised  in  making  the  skin  incision,  for  the  skin  and  subcutaneous 
tissues  are  greatly  attenuated  and  an  accident  may  easily  befall  the  hernial  contents. 
In  any  case,  one  must  be  cautious  in  opening  the  sac,  although  fluid  is  usually  present 
and  protects  the  bowel  from  injury.  By  inspection  of  the  contents  one  determines 
the  degree  of  injury  and  decides  upon  the  best  method  of  treatment.  If  the  con- 
tained fluid  be  clear  and  odorless,  the  strangulated  tissues  are  generally  in  a  good 
state  of  nutrition,  and  even  if  the  fluid  be  blood  tinged  and  of  slightly  stale  odor  the 
contents  may  be  but  little  changed.  After  carefully  irrigating  the  sac  contents  with 
normal  salt  solution  at  the  body  temperature  the  next  step  is  to  divide  the  constricting 
ring.     This  is  done  by  cutting  from  without  inward  with  an  ordinary  knife,  or  from 


670  HERNIA. 

within  outward  with  a  herniotome.  In  cutting  for  an  inguinal  hernia,  one  palpates 
for  and  attempts  to  avoid  the  deep  epigastric  artery.  In  femoral  hernia  the  femoral 
vein  and  the  deep  epigastric  and  femoral  arteries  may  almost  completely  surround 
the  ring,  hence  it  is  best  to  cut  down  from  without  inward  and  be  ready  to  clamp 
and  tie  any  injured  vessels.  After  the  constriction  is  cut  one  draws  gently  on  the 
contents  to  free  the  tissues  in  the  neck  and  make  sure  that  the  circulation  of  the 
blood  is  re-established.  By  careful  pressure  the  distended  gut  is  emptied  toward 
the  efferent  end.  A  moderately  injured  bowel  should  now  be  wrapped  for  several 
minutes  in  warm  moist  gauze,  and  if  it  regains  evidences  of  a  normal  circulation  it 
may  be  returned  to  the  abdomen  and  the  wound  be  closed.  If,  however,  there  be  a 
question  of  infection  of  the  sac  contents,  or  if  the  bowel  still  seems  cyanotic  and 
paralyzed,  it  should  not  be  returned  without  a  generous  surrounding  with  strips  of 
iodoform  gauze,  the  ends  of  which  fill  the  abdominal  wound. 

If  the  hernial  fluid  is  turbid  or  purulent  and  has  a  foul  fecal  odor,  if  the  intestine 
shows  extensive  mural  hemorrhage,  if  its  surface  has  lost  its  moist  glistening  ap- 
pearance, and  if  the  bowel  wall  when  pinched  into  a  fold  fails  to  show  an  elastic 
recovery  of  outline — in  such  conditions  the  surgeon's  judgment  is  put  to  the  greatest 
test.  Such  a  case  may  be  treated  by  bringing  the  affected  loop  out  of  the  wound, 
wrapping  it  loosely  in  moist  gauze,  and  leaving  it.  If  the  bowel  recovers  and  the 
wound  remains  clean,  the  bowel  may  be  returned  in  a  few  days  and  free  drainage 
left  down  to  its  granulating  surface.  In  cases  of  suspected  gangrene  Helferich 
recommends  that  a  lateral  anastomosis  be  made  between  the  afferent  and  efferent 
portions,  a  hand's-breadth  from  the  constriction  bands,  and  that  only  the  sus- 
pected loop  be  left  in  the  wound.  If  it  recovers,  it  may  be  returned  later.  If  well- 
marked  gangrene  be  present,  a  choice  is  presented  between  an  intestinal  resection 
with  anastomosis  (Barker^)  and  the  making  of  an  artificial  anus.  Usually  the 
patient  is  in  extreme  shock  and  the  time  element  is  an  important  factor  in  the 
operation.  Heretofore  the  great  objection  to  an  artificial  anus  has  been  the  fact 
that  the  patient's  general  nutrition  suffers  after  the  operation,  particularly  if  the 
opening  be  high  in  the  bowel.  Now  that  we  know  that  the  bowel  may  be  handled 
without  giving  a  general  anesthetic,  the  best  results  will  probably  be  obtained  by 
making  an  artificial  anus  under  cocain  anesthesia,  and  as  soon  as  the  patient  has 
recovered  from  the  primary  shock,  the  gangrenous  bowel  can  be  anastomosed  with- 
out giving  the  patient  an  anesthetic.  This  method  has  the  added  advantage  that 
after  a  few  hours  the  viable  intestine  can  be  selected  with  greater  accuracy,  for  it  is 
well  known  that  the  afferent  bowel  often  breaks  down  above  its  ring  of  constriction. 


INGUINAL  HERNIA. 
Inguinal  hernia  in  men  will  be  treated  of  in  a  special  chapter  in  this  work. 
This  form  of  hernia  is  of  far  less  importance  in  women.     Not  only  are  the  hernias 

^  Barker,  A.  E.:  "The  Treatment  of  Gangrenous  Hernia  by  Enterectomy,"  Lancet,  London, 
1903,  i,  pp.  1495  and  1576. 


INGUINAL    HERNIA.  671 

less  frequent  in  women,  but  when  present  the  anatomic  conditions  are  so  much 
simpler  that  the  radical  cure  involves  fewer  surgical  problems. 

The  conditions  of  embryonic  development  are  such  that  a  peritoneal  protrusion 
is  less  hkely  to  occur  in  this  region  in  the  female.  In  later  life  differences  in  occupa- 
tion make  the  primary  causes  of  hernia  less  frequent  in  the  female,  and  the  greatest 
factor  in  the  relative  frequency  in  the  two  sexes  is  probably  found  in  the  content 
of  the  inguinal  canal.  The  small  round  Hgament  of  the  female  does  not  compare 
in  size  with  the  large  spermatic  cord  and  its  ever-changing  blood-vessels. 

In  the  female  the  inguinal  hernia  is  generally  external  or  oblique  and  follows 
the  course  of  the  round  Hgament.  It  may  descend  low  enough  to  form  the  so-called 
labial  hernia. 

The  persistent  diverticulum  of  the  peritoneum  in  the  female  or  the  canal  of 
Nuck  may  predispose  to  a  congenital  hernia.  Like  the  processus  vaginalis  of  the 
male,  this  peritoneal  tube  may  be  constricted  anywhere  in  its  course  and  give  rise 
to  a  hydrocele.  It  is  usually  impossible  to  differentiate  a  congenital  from  an  ac- 
quired inguinal  hernia  in  the  female,  but  the  presence  of  a  hydrocele  with  a  hernia 
is  suggestive  of  a  congenital  hernial  sac. 

Diagnosis. — With  the  exception  of  a  few  pecuHarities  characteristic  of  each 
variety  of  hernia,  the  diagnosis  of  inguinal  hernia  is  made  on  the  presence  of  signs 
and  symptoms  common  to  all  hernias.  For  these  we  depend  upon  the  anamnesis 
and  examination.  The  patient  complains  of  pain,  and  of  a  swelling  or  tumor 
formation.  Pain  may  be  an  unimportant  symptom  even  with  large  hernias,  or  it 
may  be  severe,  and  appear  before  the  swelling  is  discovered.  It  may  be  local,  or 
reflected  to  the  abdomen  or  back,  or  in  inguinal  hernia  it  may  follow  the  distribution 
of  the  iUo-inguinal  and  genitocrural  nerves.  Associated  with  the  pain,  digestive 
disturbances  with  constipation  and  occasional  nausea  and  vomiting  are  not  uncom- 
mon symptoms.  The  patient  can  usually  tell  whether  the  tumor  developed  suddenly 
or  gradually,  whether  it  first  appeared  within  the  abdomen,  or  within  the  scrotum 
or  labium,  and  whether  it  changes  in  size.  Other  important  points  to  be  gained 
from  the  patient's  history  have  been  mentioned  under  etiology. 

The  examination  includes  inspection,  palpation,  and  percussion.  Inspection 
reveals  whether  the  swelling  corresponds  in  position  to  one  of  the  hernial  orifices; 
whether  its  outline  is  abrupt,  suggesting  a  tumor,  or  gradual,  suggesting  its  close 
connection  with  the  abdomen;  whether  it  changes  in  size  or  disappears  with  a 
change  in  the  patient's  position;  and  whether  there  is  an  impulse  on  coughing. 
Intestinal  peristalsis  can  sometimes  be  seen  in  large  hernias.  The  character 
of  the  contents  can  often  be  determined  by  the  aid  of  transmitted  light.  Palpation 
is  even  more  helpful  than  inspection  for  determining  whether  the  tumor  has  a  pedicle 
connection  with  the  abdominal  contents.  If  the  tumor  can  be  replaced  into  the 
abdomen  it  is  almost  certainly  a  hernia,  and  its  contents  may  at  times  be  determined 
by  palpation.  If  gurgling  is  felt  and  if  the  contents  are  reduced  suddenly,  intestine 
is  present.  If  the  contents  go  back  slowly  and  noiselessly,  omentum  is  present. 
Detection  of  impulse  is  a  great  aid  in  the  diagnosis  of  hernia,  but  impulse  is  some- 


672  HERNIA. 

times  felt  when  a  solid  or  cystic  tumor  lies  upon  or  occupies  the  abdominal  orifice. 
To  determine  impulse  in  the  inguinal  canal  one  places  the  index-finger  on  the 
front  of  the  testicle  and  then  pushes  upward  through  the  external  ring  invaginating 
the  scrotum.  In  the  female  the  internal  ring  is  found  through  the  skin  of  the  labium 
by  pushing  this  through  the  external  ring.  Intestinal  gurgling  may  be  best  detected 
by  aid  of  the  stethoscope.  Percussion  generally,  but  not  always,  gives  a  tympanitic 
note  if  intestine  be  present  in  the  tumor. 

The  formations  most  frequently  mistaken  for  hernia  are  lipoma,  hydrocele, 
enlarged  glands,  dislocated  testicle,  tumor  of  the  testicle,  fibroma  of  the  round 
ligament,  and  psoas  abscess.  Subperitoneal  lipoma  of  the  inguinal  region  is  rare 
and  its  diagnostic  points  will  be  mentioned  in  discussing  hernia  of  the  linea  alba. 

Hydrocele  develops  slowly  and  from  without  toward  the  abdomen,  and,  except 
in  the  very  rare  cases  of  persistent  processus  vaginalis  communicans,  cannot  be 
reduced.  It  is  connected  to  the  abdominal  cavity  by  the  spermatic  cord  or  round 
ligament  only,  and  therefore  appears  more  sharply  circumscribed  from  the  abdom- 
inal wall  and  can  be  moved  about  with  greater  freedom  than  in  the  case  of  hernia. 
Transmitted  light  shows  the  clear  contents  of  hydrocele  unless  blood  and  pus  are 
present. 

Treatment  of  Inguinal  Hernia. — The  non-operative  methods  of  treatment  have 
been  sufficiently  discussed.  The  great  development  in  the  operative  treatment  of 
hernia  during  the  past  quarter  century  has  centered  about  the  problems  concern- 
ing the  cure  of  inguinal  hernia.  Some  of  the  more  important  problems  in  contro- 
versy have  been  the  methods  of  dealing  with  the  peritoneal  sac,  the  disposition  of  the 
cord  with  its  component  parts,  the  vas  and  the  veins,  the  fate  of  the  testicle,  methods 
of  autoplasty  in  the  attempt  to  overcome  defects  in  the  abdominal  wall,  the  suture 
material,  and  the  questions  of  antisepsis,  asepsis,  and  the  healing  of  wounds. 

Americans  have  had  a  prominent  part  in  the  evolution  of  the  successful  hernia 
operation,  and  we  have  seen  that  Marcy  was  its  first  advocate,  his  written  reports 
antedating  those  of  Bassini  and  Halsted  by  several  years.  His  closure  of  the  wound 
in  separate  layers  has  now  been  replaced  by  Andrews'  imbrication  method,^  and  his 
attempt  to  restore  the  obliquity  of  the  canal  by  bringing  the  cord  out  of  the  upper 
end  of  the  wound  has  been  modified  by  some  surgeons  who  prefer  to  leave  the  cord 
undisturbed,  as  was  originally  practised  by  Czerny.  To  Gerard  belongs  the  credit 
for  first  advocating  a  return  to  the  old  method  of  treating  the  cord,  and  Bloodgood,^ 
in  reviewing  the  results  obtained  in  Halsted's  clinic,  questioned  the  necessity  of  cord 
transplantation.  The  best  disposition  of  the  cord  is  still  an  open  question.  The 
chief  value  of  the  imbrication  method-undoubtedly  lies  in  the  fact  that  it  compels  a 
neat  surgical  dissection  and  frees  the  lower  portion  of  the  internal  oblique  muscle. 

To  Bull  and  Coley,  of  New  York,  belongs  the  credit  of  having  popularized  the 
Bassini  operation  in  this  country. 

The  operation  for  inguinal  hernia  in  women  is  comparatively  simple,  particularly 

^  Andrews:  Chicago  Medical  Recorder,  Aug.,  1895,  vol.  ix,  p.  67. 
2  Bloodgood:  Johns  Hopkins  Hosp.  Rep.,  1898,  vii,  p.  226. 


INGUINAL    HERNIA.  673 

to  the  surgeon  who  has  mastered  the  principles  of  the  operation  on  men,  and  for  this 
reason  the  reader  in  referred  to  the  chapter  treating  of  inguinal  hernia  in  men. 
The  only  special  feature  about  the  operation,  as  performed  in  women,  is  the  presence 
of  the  round  ligament.  If  the  position  of  the  uterus  is  normal  this  may  be  disre- 
garded. If  the  uterus  is  retroverted  and  the  pelvic  organs  free  from  disease,  the 
round  ligaments  may  be  shortened  and  included  in  the  sutures  which  fasten  the 
internal  oblique  to  Poupart's  ligament,  thus  curing  the  displacement  of  the  uterus 
as  well  as  the  hernia. 

Local  Anesthesia  in  Hernia  Operations. — Alention  has  been  made  of  the 
value  of  local  anesthesia  in  hernia  operations  on  the  aged  and  on  obese  patients 
with  strangulation.  Other  positive  indications  for  the  use  of  this  method  are  certain 
bronchial,  pulmonary,  cardiovascular,  and  kidney  affections.  Gushing,^  of  Balti- 
more, has  done  valuable  work  on  the  anatomic  and  clinical  features  of  nerve  block- 
ing in  the  inguinal  region,  and  we  quote  freely  from  his  instructions  regarding  in- 
guinal hernia. 

"Individuals  advanced  in  years  are  usually  kept  in  bed  for  a  day  or  two  pre- 
liminary to  the  operation,  to  give  an  indication  of  their  ability  to  endure  recumbency, 
and  for  the  purpose  of  training  them  to  void  their  urine  in  this  position.  Evacua- 
tion of  the  bladder  is  usually  accomplished  by  the  aid  of  an  enema  if  any  postural 
difficulty  is  experienced. 

"It  has  been  the  custom  to  administer  hypodermically  a  tenth  or  an  eighth  of  a 
grain  of  morphin  three-quarters  of  an  hour  before,  and  to  repeat  this  shortly  before 
the  operation.  The  drug  must  be  used  with  caution,  however,  since  occasionally 
even  small  doses  of  morphin  in  old  people  may  confine  the  bowels  and  lead  to  dis- 
tention, which  may  be  troublesome.  Similarly,  in  old  people  with  tardy  bladders 
it  may  inhibit  the  proper  evacuation  of  the  urine,  though  we  have  never  had  the 
misfortune  to  observe  this. 

"Patients  past  middle  age  are  usually  shaved  and  prepared  on  the  operating 
table,  to  avoid  any  exposure  incidental  to  an  open  ward  preparation.  The  skin  in 
the  line  of  proposed  incision  is  infiltrated  with  Schleich's  cocain  solution,  and  the 
incision  may  be  immediately  made  through  the  linear  wheal  thus  produced 
(Fig.  789).  It  is  common  experience  to  find  the  infiltrated  tissues  more  vascular 
than  usual,  and  it  is  important  that  all  bleeding  points  be  immediately  clamped, 
since  a  dry  and  unstained  field  is  essential  to  the  success  of  the  dissection.  It  is 
unnecessary  and  useless  to  attempt  to  anesthetize  the  panniculus.  As  Schleich  has 
shown,  only  tissues  which  can  be  'edematized'  are  fitted  for  the  infiltration  method, 
and  in  the  panniculus,  at  the  upper  angle,  practically  no  nerves  are  encountered. 
If,  however,  throughout  its  whole  length  this  incision  is  carried  down  to  the  aponeu- 
rosis, unanesthetized  fibers  of  the  iliohypogastric  will  be  encountered  in  the  super- 
ficial fat  at  the  lower  angle,  together  with  one  or  two  large  veins,  division  of  which 
is  painful,  so  that  anesthetization  of  the  panniculus  layer  is  here  necessary,  or  else, 
as  has  been  done  on  several  occasions,  the  incision  only  at  the  upper  angle  may  be 

^  Gushing:  Ann.  of  Surgery,  Jan.,  1900,  xxxi,  p.  1. 
VOL.  II — 43 


674 


HERNIA. 


carried  down  to  the  aponeurosis,  which  is  then  opened  in  the  hne  of  fibers  from 
the  external  ring,  and  the  ihohypogastric  and  inguinal  nerves  immediately  cocainized 
with  a  1  per  cent,  solution  as  they  lie  under  it.  After  this  procedure  the  lower  angle 
of  the  incision  may  be  painlessly  carried  down  to  the  external  ring,  and  the  remaining 
intercolumnar  fibers  of  the  aponeurotic  insertion  then  divided.  There  is,  under 
ordinary  circumstances,  no  further  need  of  the  anesthetic,  as  we  are  working  in  an 


anterior  cutan^scf  12. (io4 


anterior  cutaris  of  i.luW 
(ilio-hypog.)  f 

Intern,  ring"' 
Ext.  ring f 


Lateral  cut.of  12.  d. 
--Ant.5up.5pine 
hat. cut. of  II 


superfic. 
of  pucLic  '3Ns^ 

Infer,  pudendal 

Fig.  789. — Sites  for  Local  Anesthesia  in  the  Inguinal  Region  (after  Gushing). 

area  freed  from  all  sensation.  The^combined  ilio-inguinal  and  genital  branch, 
which  has  been  cocainized  at  the  outer  limit  of  its  exposure,  is  now  reflected  to  one 
side  or  the  other,  care  being  taken  not  to  divide  it,  since  this  leads  apparently  to  a 
more  or  less  permanent  paralysis  of  the  cremaster,  which  is  to  be  avoided.  I  believe 
the  accidental  division  of  this  nerve  leads  to  the  great  relaxation  of  the  scrotum  so 
often  seen  after  hernia  and  varicocele  operations.  In  the  latter  operation,  especially, 
it  would  be  detrimental  to  the  best  interests  of  a  successful  result  to  interfere  with 


FEMORAL    HERNIA.  675 

the  cremasteric  function  in  any  way.  The  remainder  of  the  operation — the  ex- 
posure of  the  sac  and  cord  after  a  longitudinal  division  of  the  infundibuliform  fascia, 
the  amputation  of  the  sac  at  its  neck,  and  closure  of  the  peritoneal  opening,  the  ex- 
cision of  the  fundus  of  the  sac,  division  of  the  cord,  and  castration,  if  deemed  advis- 
able— may  now  be  done  practically  without  pain.  Occasionally,  however,  some 
stray  fibers  of  the  genitocrural  may  be  encountered  about  the  neck  of  the  sac,  and 
also  during  castration  I  have  found  that  ligation  of  the  veins  at  the  lower  pole  of  the 
testicle  may  be  painful,  though  division  of  the  cord  above  is  not.  Possibly  the 
superficial  perineal  branches  which  have  been  unanesthetized  furnish  nerves  to 
this  lower  blood-supply." 

A  recent  communication  by  J.  A.  Bodine,^  of  New  York,  reporting  three  hundred 
cases  of  inguinal  hernia  operated  on  under  local  anesthesia  contains  many  practical 
suggestions  and  is  worthy  of  careful  study. 

FEMORAL  HERNIA. 

Femoral  hernia,  while  less  frequent  in  women  than  the  inguinal  variety,  is 
much  more  frequent  in  women  than  in  men.  It  claims  the  especial  attention  of  the 
abdominal  surgeon  today  because  of  the  less  settled  state  of  its  therapeutics  as  com- 
pared with  inguinal  hernia. 

According  to  Coley,^  femoral  hernia  has  a  slightly  higher  mortality  and  a  smaller 
percentage  of  permanent  cures  than  inguinal. 

Of  one  hundred  women  affected  with  hernia,  32.7  per  cent,  have  femoral  while 
44.3  per  cent,  have  inguinal  hernia  (Berger).  Macready^  gives  the  proportion  of 
inguinal  to  femoral  in  the  female  as  6  : 4.  Pott*  collected  a  series  of  15,028  operations 
for  inguinal  and  femoral  hernia,  of  which  14,092  were  for  inguinal  and  933  for 
femoral,  showing  a  proportion  of  fifteen  inguinal  to  one  femoral. 

Coley,  in  doing  one  hundred  and  seventeen  operations  for  femoral  hernia  in 
one  hundred  and  five  patients,  found  thirty-four  of  the  operations  in  children  between 
the  ages  of  two  and  fourteen  years,  while  eighty-three  operations  were  done  upon 
adults,  or  patients  between  fourteen  and  seventy  years  of  age.  The  infrequency 
of  occurrence  in  childhood  is  due,  no  doubt,  to  the  fact  that  the  femoral  ring  is 
small  until  its  widening  coincident  with  the  growth  of  the  pelvis  at  puberty.  Coley's 
statistics  show  that  in  children  the  relative  frequency  of  femoral  hernia  in  males  to 
females  is  one  to  two,  while  in  adults  it  is  about  one  to  six. 

Anatomy. — A  reference  to  Figs.  790  and  791  recalls  the  anatomy  of  the  femoral 
region.  A  femoral  hernia  has  no  preformed  canal  corresponding  to  the  inguinal 
canal,  but  makes  a  path  as  it  descends,  pushing  ahead  of  it  or  to  one  side  the  peri- 
toneum, the  so-called  septum  crurale  of  the  transversalis  fascia,  the  lymphatic  glands, 
and  the  loose  areolar  tissues  of  the  space  through  which  it  passes.     As  it  leaves  the 

1  Bodine,  J.  A.:  Medical  Record,  1905,  Ixviii,  p.  645. 

^  Coley:  "The  Radical  Cure  of  Femoral  Hernia,"  Ann.  of  Surgery,  1906,  xliv,  519. 

^  Macready,  Jonathan:  "A  Treatise  on  Ruptures,"  1893,  London. 

*  Pott:  Deutsche  Zeitschr.  f.  Chir.,  1903,  Ixx,  S.  556. 


676 


HERNIA. 


abdominal  cavity  its  sac  passes  through  a  ring  formed  by  the  fibrous  covering  of  the 
femoral  vein  externally,  the  processes  of  transversalis  and  iliac  fasciae  meeting  over 
the  outer  edge  of  Gimbernat's  ligament  internally,  Poupart's  ligament  anteriorly, 
and  the  iHac  fascia  lying  over  the  pubic  ramus  posteriorly.  The  sac  descends  along 
the  vein  and  pushes  ahead  of  it  the  cribriform  fascia  of  the  saphenous  opening. 
Its  investing  tissues  are  often  so  thinned  that  the  sac  is  encountered  immediately 
below  the  skin. 


Perineal  hernials 


Fig.  790. — Anatomy  op  the  Femoral  Region. 


Diagnosis. — The  diagnosis  of  femoral  hernia  is  generally  not  difficult  if  careful 
attention  is  given  to  the  anamnesis  and  examination.  In  most  femoral  hernias 
inspection  shows  the  protrusion  to  lie  below  Poupart's  ligament,  but  there  are  cases 
in  which  femoral  hernia  develops  upward  in  front  of  Poupart's  ligament  and  in 
which  the  diagnosis  is  difficult  even  with  the  aid  of  palpation.  To  differentiate 
between  femoral  and  inguinal  hernia  the  neck  of  the  sac  must  first  be  located  and  then 


FEMORAL   HERNIA.  677 

its  position  determined  with  reference  to  Poupart's  ligament.  This  is  sometimes 
difficult  in  obese  individuals,  particularly  if  the  hernia  be  large,  and  the  diagnosis 
becomes  most  difficult  if  the  hernia  is  irreducible  or  strangulated.  Subperitoneal 
lipoma  is  prone  to  occupy  the  femoral  canal,  and  in  this  position  may  form  a  tumor 
which  produces  the  symptoms  and  shows  many  signs  characteristic  of  hernia.  If  a 
femoral  hernia  pushes  between  the  septa  of  the  cribriform  fascia  it  may  form  a 
dense  nodulated  tumor  mass  which  is  irreducible  and  very  difficult  to  differentiate 
from  enlarged  glands.  Varicose  veins  of  the  femoral  region  occur,  with  enlarged 
veins  elsewhere  over  the  leg,  and  a  thrill  can  be  felt,  and  with  the  stethoscope  a 
humming  murmur  heard  over  the  varix.  Cysts  of  the  hernial  sac  may  complicate 
the  diagnosis.  ■ 

Because  of  the  firm  character  of  its  surrounding  tissues  the  neck  of  a  femoral 
hernia  is  particularly  liable  to  constrict  the  sac  and  cause  strangulation.  This  is 
usually  of  the  elastic  variety  and  is  apt  to  be  complete  from  the  beginning;  thus 
rendering  taxis  a  procedure  which  in  most  cases  is  not  only  useless  but  positively 
dangerous.  When  bowel  obstruction  and  other  symptoms  of  hernia  are  present,  the 
surgeon  should  always  make  a  most  careful  examination  of  the  femoral  region,  for 
lateral  strangulation  of  the  bowel  wall  is  most  frequently  through  this  aperture,  and 
nothing  may  be  found  but  a  very  small  tender  swelling  to  the  inner  side  of  the  femoral 
vessels. 

Treatment  of  Femoral  Hernia. — The  truss  treatment  of  femoral  hernia  is 
even  less  satisfactory  than  for  the  inguinal  variety.  In  this  region  it  is  difficult  to 
fit  a  truss  that  will  not  be  displaced  by  the  different  movements  of  the  hip-joint. 
The  measurement  for  the  steel  band  should  be  made  in  the  circumference  of  the 
pelvis  midway  between  the  anterior  superior  spine  and  the  great  trochanter.  While 
in  inguinal  hernia  the  pad  lies  parallel  to  Poupart's  ligament,  in  femoral  hernia 
it  should  be  more  vertical  and  usually  of  small  size. 

Operation. — In  no  better  way  can  the  imsettled  state  of  the  therapeutics  of  femoral 
hernia  be  illustrated  than  by  making  a  comparison  of  two  recent  papers  by  recognized 
authorities. 

Ochsner^  advises  the  method  originally  advocated  by  Socin.^  Acting  on  the 
well-known  surgical  principle  "that  it  is  practically  impossible  to  keep  a  circular 
opening  in  any  part  of  the  body  from  closing  spontaneously  unless  it  be  lined  with  a 
mucous  or  serous  membrane,"  Ochsner  advises  the  simple  plan  so  long  in  vogue: 
viz.,  "to  dissect  out  the  hernial  sac  quite  up  into  the  peritoneal  cavity  beyond  the 
inner  surface  of  the  femoral  ring,  ligate  it  high  up,  cut  it  off  and  permit  the  stump 
to  withdraw  within  the  peritoneal  cavity.  Removing  all  the  fat  contained  in  the 
femoral  canal  and  simply  closing  the  skin  wound  completes  the  operation  for  femoral 
hernia.  This  method  is  applicable  to  all  simple  femoral  hernias  in  which  an  actual 
femoral  ring  exists." 

Coley,^  on  the  other  hand,  says  that  in  the  earlier  operation  of  simple  excision 

1  Ochsner:  "Femoral  Herniotomy,"  Jour.  Am.  Med.  Assoc,  1906,  xlvii,  751. 

2  Socin:  Langenbeck's  Archiv,  1879,  xxiv,  S.  391.  ^  Coley:  Loc.  cit. 


678 


HERNIA. 


of  the  sac  without  attempt  to  close  the  canal  there  was  a  recurrence  within  a  year  in 
30  to  40  per  cent,  of  the  cases.  He  quotes  Potts'  statistics  covering  933  cases  of 
femoral  hernia  as  showing  63.3  per  cent,  of  cures  when  the  sac  was  simply  excised 
and  the  wound  closed  without  suture  of  the  canal,  while  there  were  76.4  per  cent, 
cured  by  the  methods  including  canal  closure. 

Coley  uses  with  slight  modification  the  operation  first  described  by  Gushing,  of 
Boston,  and  describes  the  operation  as  follows.     (See  Fig.  791.)     "An  oblique 


Femoral  y^i^- 
Fascia  lata:— - 


'.sapbe/idmagiu- 

I  \ 


Fig.  791. — Cushing's  Operation  for  the  Radical  Cure  of  Femoral  Hkrxia. 

incision  is  made  one-quarter  to  one-half  inch  below  Poupart's  ligament  and  parallel 
with  it,  almost  identical  with  the  incision  made  for  inguinal  hernia,  only  slightly 
lower  and  a  little  shorter.  The  sac  with  the  mass  of  extraperitoneal  fat  that  almost 
always  surrounds  it  is  then  freed  well  up  into  the  femoral  opening.  The  masses  of 
fat  are  carefully  removed,  the  sac  itself,  by  gentle  traction,  is  brought  down  well 
beyond  its  neck  to  a  point  where  it  widens  into  the  general  peritoneal  ca^dty.  It  is 
always  opened  before  ligature,  to  make  sure  that  it  is  empty.  If  omentum  is  present, 
this  is  tied  off  and  removed.     The  ligature  having  been  placed  well  beyond  the  neck 


FEMORAL    HERNIA,  679 

by  transfixion,  it  is  carefully  tied  and  the  sac  removed.  When  the  stump  of  the  sac 
has  been  pushed  through  the  opening  into  the  abdominal  cavity,  there  is  no  longer 
any  funicular  process  present  in  the  femoral  region.  With  a  curved  Hagedorn 
needle,  threaded  with  kangaroo  tendon,  of  medium  size,  the  suture  is  placed  as 
follows:  The  needle  is  first  passed  through  the  inner  portion  of  Poupart's  ligament 
or  the  roof  of  the  canal,  then  downward,  taking  firm  hold  of  the  pectineal  fascia  and 
muscle,  then  outward  through  the  fascia  lata  overlying  the  femoral  vein,  and  finally 
upward,  emerging  through  the  roof  of  the  canal  about  one-quarter  inch  distant  from 
the  point  of  entrance.  On  tying  this  suture,  the  floor  of  the  canal  is  brought  into 
apposition  with  the  roof,  and  the  femoral  opening  is  completely  obliterated.  The 
skin  and  superficial  fascia  are  closed  by  means  of  an  interrupted  catgut  suture  and  a 
sterile  dressing  is  applied,  without  drainage.  The  first  change  of  dressing  is  made 
at  the  end  of  one  week.  The  patient  is  kept  in  bed  for  two  weeks  and  allowed  to 
go  home  at  the  end  of  two  and  a  half  weeks.  A  firm  spica  bandage  is  worn  one  week 
after  leaving  the  hospital,  at  the  end  of  which  time  no  further  support  is  needed." 

To  more  effectually  fill  the  femoral  canal  various  plastic  operations  have  been 
devised.  Salzer*  took  a  flap  from  the  pectineal  fascia,  and,  leaving  its  apex  intact 
at  the  upper  end,  he  transplanted  the  free  lower  end  and  sutured  it  to  Poupart's 
ligament  in  such  a  way  that  the  femoral  canal  was  closed.  Watson  Cheyne^  turns  up 
a  flap  of  the  pectineus  muscle  and  fascia.  INIoullin^  uses  the  pectineus  and  adductor 
longus.  Schwartz*  uses  the  adductor  longus,  and  Finney^  independently  devised 
the  same  operation.  Finney  has  returned  to  the  purse-string  operation,  which  he 
had  used  with  satisfaction  for  many  years. 

Of  the  various  heteroplastic  methods,  Trendelenburg"  reported  at  the  Nineteenth 
Congress  of  the  German  Surgical  Association  the  insertion  of  a  bone  plate  to  aid  in 
fining  the  hernial  ring,  thus  being  the  first  to  use  a  foreign  body  in  the  closure  of  a 
hernia.  Later  he  turned  down  a  pediculated  periosteal  bone  flap  chiseled  from  the 
pubic  bone.  Thiriar,^  of  Brussels,  sutures  a  decalcified  bone  plate  over  the  femoral 
ring  from  within  the  abdomen.  Roux,  of  Lausanne,  drives  a  metal  staple  through 
Poupart's  ligament  into  the  pubic  bone.  The  work  of  Witzel  and  of  Goepel,  in 
which  they  used  permanent  silver  wire  netting  for  the  closure  of  large  hernial  aper- 
tures, will  be  spoken  of  under  umbilical  hernia. 

Methods,  such  as  that  of  Gordon,^  requiring  the  closure  to  be  done  from  above 
Poupart's  ligament,  and  of  Lotheissen,**  who  fastens  the  conjoined  tendon  to  the 
pubic  ramus,  seem  unnecessarily  complicated,  and  must  be  less  successful  than  the 
simpler  methods  except  in  the  hands  of  surgeons  of  broad  experience. 

Noble  (private  communication)  reports  that  since  1892  he  has  operated  without 

1  Salzer:  Centralbl.  f.  Chir.,  1892,  xix,  S.  665. 

2  Cheyne,  Watson:  Lancet,  London,  1892,  ii,  1039.         =  .Aloullin:  Lancet,  London,  1896,  i,  479. 
■*  Schwartz:  Congres  de  Chir.,  Proc.  verb.,  Paris,  1893,  vii,  689. 

5  Finney:  Md.  Med.  Jour.,  1899,  xli,  151. 

«  Trendelenburg:  Centralbl.  f.  Chir.,  1890,  Beilage,  S.  61. 

'Thiriar:  Congres  de  Chir.,  Proc.  verb.,  Paris,  1893,  vii,  318. 

«  Gordon:  Brit.  Med.  Jour.,  1900,  i,  1338.        »  Lotheissen:  Centralbl.  f.  Chir.,  1898,  xxv,  548. 


680  HERNIA. 

known  recurrences  as  follows:  A  vertical  incision  is  made  over  the  hernial  mass,  and 
the  sac  and  attached  fat  are  separated  up  to  its  neck.  After  the  hernia  is  reduced  the 
sac  is  removed  and  sutured  at  its  neck,  after  which  its  peritoneum  retracts  within 
the  abdomen.  A  silkworm-gut  suture  threaded  through  a  round  curved  needle  is 
passed  from  above  downward  through  Poupart's  hgament  and  (the  femoral  vein 
being  retracted  outward)  then  through  the  fibrous  structures  over  the  ramus  of  the 
pubis;  it  is  then  reintroduced  from  below  upward  through  Gimbernat's  ligament 
and  next  through  Poupart's  ligament,  when  the  suture  is  tied.  This  obhterates  the 
canal.  The  skin  is  then  sutured.  The  method  has  given  uniformly  good  results 
with  primary  heahng  of  the  wound  in  every  case. 


UMBILICAL  HERNIA. 

Umbilical  hernia  may  be  considered  under  three  classes:  (1)  congenital  hernia 
of  the  umbihcal  cord;  (2)  the  umbihcal  hernia  of  children;  and  (3)  the  umbiKcal 
hernia  of  adults.  The  first  class  includes  by  far  the  greater  number,  and  they  range 
in  size  from  those  containing  only  Meckel's  diverticulum,  v/hich  may  be  inadver- 
tently tied  and  cut  with  the  cord,  to  those  as  large  as  a  child's  head,  containing  a 
large  portion  of  the  abdominal  viscera. 

These  congenital  hernias  of  the  cord  are  really  cases  of  ectopia  or  malformation, 
for  they  represent  a  failure  of  the  abdominal  viscera  to  completely  withdraw  from  an 
original  fetal  position,  rather  than  a  hernia  or  protrusion  through  the  abdominal  wall. 

Care  should  always  be  exercised  in  ligating  the  cord  that  there  be  no  unusual 
sweUing  or  protrusion  about  its  proximal  end.  If  a  loop  of  gut  or  the  diverticulum 
of  Meckel  be  discovered,  the  contents  should  be  carefully  reduced  and  held  in  place 
by  a  sterile  wad  of  gauze  firmly  bound  over  the  cord.  Adhesive  straps  may  be  used 
and  so  placed  as  to  bring  the  recti  muscle  in  apposition.  For  the  larger  hernias  the 
indication  is  a  reduction  of  the  contents,  excision  of  the  sac,  and  apposition  of  the 
walls,  at  the  earhest  possible  moment  consistent  with  good  technic.  For  the  very 
large  hernias,  containing  so  much  of  the  abdominal  viscera  that  their  return  will 
interfere  with  the  vital  function,  the  outlook  is  necessarily  bad. 

The  umbilical  hernias  of  childhood  occur  most  frequently  in  the  first  year  of  Hfe. 
Indeed,  there  are  probably  many  umbilical  hernias  during  the  first  few  years  of  life 
which  undergo  spontaneous  cure  and  are  never  noticed.  In  the  process  of  atrophy 
of  the  cord  and  cicatrizing  of  the  tissues  about  its  base  there  is  left  the  umbilical  ring, 
into  which  dip  the  umbiKcal  vein  above  and  the  arteries  below.  This  ring  becomes 
contracted  and  firm  only  with  the  progress  of  time,  and  it  seems  riemarkable  that  the 
crying  and  straining  of  the  first  few  weeks  of  life  do  not  result  in  more  hernias. 
The  protrusion  generally  takes  place  through  the  upper  border  of  the  ring,  as  the 
large,  loosely  attached  vein  in  this  region  offers  less  resistance  than  the  more  firmly 
attached  arteries  at  the  inferior  border.  If  the  hernia  be  small,  it  is  usually  globular; 
while  if  larger,  it  becomes  conical. 

Many  hernias  of  this  class  undergo  spontaneous  cure.     Many  more  may  be 


UMBILICAL    HERNIA. 


681 


cured  by  proper  bandaging.  A  good  method  is  the  early  appHcation  of  adhesive 
straps  appHed  in  such  manner  that  the  skin  over  the  hernia  is  brought  together  in 
folds,  acting  as  a  buttress.  If  the  child  is  older,  one  may  use  a  silk  elastic  bandage 
which  passes  entirely  around  the  body  and  contains  a  broad  pad  or  button  to  cover 
the  hernial  orifice.  If  the  hernia  is  not  cured  by  the  tenth  year,  operation  is 
advisable.  This  consists  in  omphalectomy  with  apposition  of  the  separate  layers 
of  the  abdominal  wall. 

Umbilical    hernia 
of  adults  is  rare  and 
found  most  often  in 
women  who  have  had 
repeated  pregnancies. 
Obesity  is  an  impor- 
tant   cause,   particu- 
larly if  the  abdominal 
walls  suddenly  become  lax  from  rapid 
emaciation.     Hernia  of  the  umbilicus 
may  reach  a  large  size,  and  from  the 
exposed     position    be    subjected    to 
mechanical  insult,  resulting  in  serious 
phenomena    of    inflammation,    such 
as    adhesions,    formation    of    serous 
pockets,  irreducibility,  and  strangula- 
tion  of    all  or   part  of    its  contents. 
Formerly  the    high    death-rate   from 
operation  (50  per  cent.)  in  this  class 
of  cases  led   to   the   devising  of   all 
manner  of  harness  for  the  retention 
of  these  hernias.     Since  the  general 
adoption  of    the   plan  advocated  by 
Wm.  J.  Mayo,^  of  operation  by  over- 
lapping the  abdominal  walls  vertically, 
there  are  few  such  cases  that  cannot 
be  given  a  large  measure  of  hope  by 
the  experienced  surgeon.     That  pa- 
tients see  the  surgeon  in  an  earlier 
period  in  the  development  of  the  malady  is  also  a  factor  in  the  improved  statistics. 

Our  former  efforts  at  closure  of  the  umbilical  hernia  by  lateral  flap  methods  are 
well  represented  by  the  description  of  Piccoli,^  who  aimed  by  splitting  and  overlapping 
to  get  a  strong  double  layer  of  abdominal  wall  in  place  of  the  opening.  But  those 
who  have  attempted  to  replace  voluminous  contents  in  a  contracted  abdominal  cavity 
and  then  to  close  the  large  opening  by  making  use  of  the  atrophied  tissues  laterally, 

iMayo,Wm.  J.:  Ann.  of  Surg.,  1899.  xxix,  51.       ^  pjcpoii.  Centralbl.  f.  Chir..  1900,  xxvii,  36. 


Fig.  792. — Operation  for  the  Radical  Cure  of  Umbili- 
cal Hernia,  Mayo's  Method. 
Showing  the  transverse  incision,  exposure  of  the  apo- 
neurosis of  the  recti,  circular  division  of  the  neck  of  the  sac, 
transverse  incisions  in  aponeurosis. 


682 


HERNIA. 


can  best  appreciate  the  attempts  of  various  surgeons  to  find  some  mechanical  ap- 
pliance to  fill  in  the  defects  of  autoplasty.  O.  Witzel/  of  Bonn,  closed  large  hernial 
apertures  by  weaving  in  a  fine  meshwork  of  silver  wire;  while  Goepel,  of  Leipzig, 


Fig.  793.— Operation  for  thk  Radical  Cure  of  Umbilical  Hernia,  Mayo's  Method  (Kelly). 

in  the  same  journal  reported  work  with  ready-made  silver  wire  netting,  and  claims 
for  his  methods  of  implantation  of  the  silver  filigree  pad,  the  advantage  of  less 
injury  to  the  tissues,  less  time  for  operation,  an  even  network  of  wire  that  will  not 

1  Witzel,  O.:  Centralbl.  f.  Chir.,  1900,  xxvii,  pp.  257,  457,  1149. 


UMBILICAL   HERNIA. 


683 


spread  at  any  point,  and  a  minimum  amount  of  wire  left  in  the  tissues.  He  has 
pads  made  in  various  sizes  and  shapes  to  correspond  to  the  size  of  the  hernial  orifice 
and  to  the  anatomic  outline  of  the  portion  of  the  body  in  which  the  hernia  occurs. 


Fig.  794.— Operation  for  the  Radical  Cure  of  Umbilical  Hernia,  Mayo's  Method  (Kelly). 


The  pad  overlaps  the  hernial  orifice  and  is  strongly  fastened  to  the  surrounding 
tissues  with  silver  sutures.    Phelps/  of  New  York,  had  been  working  with  the  hetero- 
plastic methods  since  1892,  but  did  not  publish  his  results  until  September  22,  1900. 
1  Phelps:  N.  Y.  Med.  Record,  1900,  Iviii,  441. 


684  HERNIA, 

Willy  MeyerV  reports   three  cases    in  which   he   has   used  the  ready-made  silver 
filigree  pads. 

The  operation  first  pubhshed  by  Mayo,^  and  which  has  revolutionized  the 
results  in  this  difficult  class  of  cases,  is  described  as  follows  (Figs.  792,  793,  794) : 

1.  Transverse  elliptical  incisions  are  made  surrounding  the  umbilicus  and  hernia; 
this  is  deepened  to  the  base  of  the  hernial  protrusion. 

2.  The  surfaces  of  the  aponeurotic  structures  are  carefully  cleared  2h  to  3  inches 
in  all  directions  from  the  neck  of  the  sac. 

3.  The  fibrous  and  peritoneal  coverings  of  the  hernia  are  divided  in  a  circular 
manner  at  the  neck,  exposing  its  contents.  If  intestinal  viscera  are  present,  the 
adhesions  are  separated  and  restitution  made.  The  contained  omentum  is  ligated 
and  removed  with  the  entire  sac  of  the  hernia  and  without  tedious  dissection  of  the 
adherent  portions  of  the  omentum. 

4.  An  incision  is  made  through  the  aponeurotic  and  peritoneal  structures  of  the 
ring  extending  one  inch  or  less  transversely  to  each  side,  and  the  peritoneum  is 
separated  from  the  under  surface  of  the  upper  of  the  two  flaps  thus  formed. 

5.  Beginning  from  2  to  2^  inches  above  the  margin  of  the  flap,  three  or  four 
mattress  sutures  of  silk  or  other  permanent  material  are  introduced,  the  loop  firmly 
grasping  the  upper  margin  of  the  lower  flap;  sufficient  traction  is  made  on  these 
sutures  to  permit  peritoneal  approximation  with  running  suture  of  catgut.  The 
mattress  sutures  are  then  drawn  into  position,  sliding  the  entire  lower  flap  into 
the  pocket  previously  formed  between  the  aponeurosis  and  the  peritoneum 
above. 

6.  The  free  margin  of  the  upper  flap  is  fixed  by  catgut  sutures  to  the  surface 
of  the  aponeurosis  below,  and  the  superficial  incision  closed  in  the  usual  manner. 
In  the  larger  hernias  the  incision  through  the  fibrous  coverings  of  the  sac  may  be 
made  somewhat  above  the  base,  thereby  increasing  the  amount  of  tissue  to  be  used 
in  the  overlapping  process." 

The  ease  of  performing  this  operation,  the  shortened  anesthesia,  the  relatively 
slight  handling  of  the  sac  contents,  and  the  comparative  ease  of  closing  the  wound 
without  bringing  about  a  tremendous  increase  of  intra-abdominal  pressure,  are  a  few 
of  the  factors  which  have  changed  one  of  oiir  most  dangerous  and  dreaded  surgical 
procedures  into  an  operation  of  comparative  ease  and  safety. 

VENTRAL  HERNIA. 
Under  this  designation  are  included  all  hernias  of  the  anterior  abdominal  wall 
except  umbilical  and  inguinal  hernias.     According  to  their  location,  we  speak  of 
median  ventral  hernia,  or  hernia  of  the  linea  alba,  and  lateral  ventral  hernia.     Those 

'  Meyer,  Willy:  Ann.  of  Surgery,  1902,  xxxvi,  767.  \ 

2  Mayo:  Jour.  Am.  Med.  Assoc,  1903,  xli,  225.  Charles  P.  Noble,  of  Philadelphia,  who 
since  1896  has  been  an  enthusiastic  advocate  of  the  overlapping  method  in  closing  wounds  of  the 
abdominal  wall,  had  already  closed  large  umbilical  hernias  by  overlapping  from  above  downward 
(Ann.  of  Surgery,  March,  1906,  xliii),  his  first  operation  with  overlapping  from  above  down- 
ward being  performed  Feb.   14,   1898,  and  his  operation  with  lateral  overlapping  in  1894. 


VENTRAL   HERNIA.  685 

hernias  occurring  in  the  median  aponeurosis,  even  if  they  be  to  one  side  of  the  Hnea 
alba,  are  classed  with  the  median  ventral  hernias. 

In  this  day  of  abdominal  surgery  by  far  the  greater  number  of  ventral  hernias 
are  post-operative,  and  to  these  a  special  section  will  be  given.  The  following 
observations  on  the  development  and  frequency  of  ventral  hernia  are  made  without 
reference  to  the  post-operative  variety. 

The  linea  alba  is  formed  by  the  interlacement  of  aponeurotic  fibers  from  the  two 
sides,  and  as  it  descends  from  the  xiphoid  process  to  the  umbilicus  it  grows  broader 
and  thinner.  Below  the  umbilicus  the  linea  alba  is  narrower  and  thicker.  Hernia 
of  the  linea  alba  is  common  above  the  umbilicus,  and  in  this  situation  is  known  as 
epigastric  hernia.  Hernia  of  the  linea  alba  lying  immediately  above  the  umbilicus 
may  so  overhang  this  region  that  it  is  confounded  at  birth  with  hernia  of  the  umbilical 
cord,  but  in  such  cases  careful  examination  enables  one  to  trace  the  cord  back  to  the 
abdominal  wall. 

Occurring  usually  in  adult  life,  epigastric  hernia  is  generally  supposed  to  be  due 
to  some  congenital  or  acquired  defect  in  the  fascia  of  the  linea  alba,  through  which 
the  peritoneum  and  hernial  contents  find  their  way  on  the  occurrence  of  some  unus- 
ual trauma  or  pressure  from  within.  It  is  usually  stated  that  pregnancy  is  a  promi- 
nent factor,  but  Berger's  figures  are  striking  in  this  regard.  Of  10,000  hernia 
patients,  137  had  the  epigastric  variety,  and  117  of  these  were  in  males,  while  only  12 
were  in  females  above  the  age  of  fifteen.  In  speaking  of  hernia  we  must  carefully 
exclude  diastasis  of  the  recti,  so  often  seen  in  parturient  women,  and  the  analogous 
supra-umbilical  eventration  seen  in  the  crying  child. 

Perhaps  one  of  the  most  frequent  causes  of  ventral  hernia,  and  surely  the  most 
difficult  factor  in  diagnosis,  is  the  subperitoneal  hpoma.  These  subperitoneal  fatty 
tumors  are  most  common  in  the  linea  alba,  femoral  and  umbilical  regions.  They 
develop  from  the  layer  of  fat  lying  immediately  beneath  the  peritoneum  and  make 
their  escape  through  the  linea  alba  or  the  natural  abdominal  openings  by  following 
the  blood-vessels  which  run  from  the  subperitoneal  region  outward  into  the  abdom- 
inal walls.  Reaching  the  prefascial  region,  they  may  undergo  development  and  pre- 
sent signs  and  symptoms  that  cannot  be  distinguished  from  hernia.  They  often 
have  the  consistence  of  an  omental  hernia,  and  they  may  be  wholly  or  partially 
returned  to  their  neighboring  abdominal  orifice,  to  again  protrude  with  any  sudden 
increase  of  the  intra-abdominal  pressure,  as  from  coughing.  By  dragging  on  the 
peritoneum  they  produce  reflex  gastric  and  other  symptoms  similar  to  those  of  ab- 
dominal hernia,  and  by  pulling  out  a  diverticulum  of  peritoneum  a  beginning  hernia 
is  determined. 

The  symptoms  of  epigastric  hernia  and  of  the  frequently  associated  properitoneal 
lipoma  may  easily  be  inferred  by  considering  some  of  the  more  common  maladies 
for  which  they  are  mistaken.  The  incidence  of  epigastric  hernia  (about  1  per  cent, 
of  all  hernia  cases)  is  not  an  indication  of  its  great  importance.  Too  little  attention 
has  been  given  in  the  literature  to  the  relative  frequency  with  which  patients  suffering 
from  this  easily  cured  malady  are  subjected  to  all  manner  of  treatment  for  obscure 


686  HERNIA. 

abdominal  conditions.  Kuttner^  makes  an  exhaustive  review  of  the  literature  and 
finds  this  condition  mistaken  for  gastralgia,  enteralgia,  gastric  ulcer,  and  carcinoma, 
for  cholelithiasis,  and  for  neurasthenia,  hysteria,  and  hypochondriasis.  More 
recently  D.  D.  Stewart^  has  emphasized  the  importance  of  this  form  of  hernia  in  the 
work  of  the  diagnostician.  Lothrop^  emphasizes  the  clinical  importance  of  the 
fatty  tumors  of  the  epigastrium  and  discusses  their  relationship  to  epigastric  hernias. 


POST-OPERATIVE  HERNIA. 
Faulty  closure  of  an  abdominal  wound,  suppuration,  and  the  use  of  drainage  are 
the  chief  factors  in  the  causation  of  post-operative  hernia.  The  use  of  catgut 
sutures  which  become  absorbed  too  soon,  and  particularly  the  placing  of  sutures  at 
wide  intervals,  are  factors  determining  the  separation  of  abdominal  wounds  which 
immediately  after  operation  seem  to  have  healed  perfectly.  The  post-operative 
distention,  vomiting,  and  coughing,  undoubtedly  serve  to  drive  a  wedge  of  omentum 
or  intestine  into  any  part  of  the  fresh  incision  not  properly  protected  by  suture, 
and  only  after  weeks  or  months  does  the  protrusion  work  its  way  outward  sufficiently 
to  be  diagnosed  as  a  ventral  hernia.  As  prophylactic  measures  we  recognize  the 
value  of  using  the  gridiron  incision  (McBurney)  whenever  possible.  For  gall-stone 
surgery  and  for  combined  operations  on  the  appendix  and  pelvic  organs  it  is  often 
advantageous  to  make  a  rectus  muscle  (Battle)  incision.  Whenever  possible,  the 
nerves  and  vessels  in  the  line  of  the  incision  should  be  respected  and  drawn  to  one 
side  rather  than  cut,  thus  preventing  post-operative  atrophy  and  weakness.  As 
most  gynecologic  operations  are  done  through  a  median  hypogastric  incision,  and 
because  of  the  great  length  of  the  incision  in  many  cases,  it  becomes  imperative  that 
great  care  be  used  in  the  closure.  C.  P.  Noble*  has  repeatedly  called  attention  to  the 
importance  of  the  overlapping  method  in  closing  wounds  of  the  abdominal  wall. 
At  the  end  of  an  operation  done  through  a  suprapubic  median  incision  a  continuous 
catgut  suture  closes  the  peritoneum.  If  this  suture  passes  through  the  peritoneum 
just  back  of  its  free  border  on  either  side,  the  free  borders  are  apposed  and  turned 
toward  the  peritoneal  cavity  to  form  a  buttress  line  which  must  aid  materially  in 
preventing  any  wedge  of  omentum  from  slipping  into  the  line  of  incision.  If  both 
rectus  sheaths  have  not  been  opened  in  making  the  initial  incision,  they  must  now 
be  opened  and  the  rectus  fibers  freed  &,nd  apposed  by  a  running  catgut  suture,  which 
occasionally  picks  up  the  peritoneum  so  as  to  prevent  the  formation  of  a  blood-clot 
between  the  peritoneal  and  muscular  layers.  Heavy  catgut  or  silk  sutures  now  over- 
lap the  outer  aponeurosis  of  the  rectus  muscles  and  give  the  wound  its  initial  strength 
until  thorough  organization  has  taken  place.     The  method  of  closure  of  the  sub- 

^  Kuttner:  Mitteilungen  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie,  1896,  Bd.  i,  No. 
26,  S.  661. 

^  Stewart,  D.  D.:  Amer.  Med.,  1905,  Bd.  x,  p.  185. 

^  Lothrop:  "Hernia  Epigastrica  and  Fatty  Tumors  in  the  Epigastrium,"  Med.  and  Surg. 
Reports  of  the  Boston  City  Hospital,  1901,  p.  66. 

'  Noble,  C.  P.:  Med.  News,  Dec.  17,  1904,  Ixxxv,  1162. 


POST-OPERATIVE    HERNIA.  687 

cuticular  fat  and  the  skin  is  immaterial  to  the  strength  of  the  wound  if  one  avoids 
infection  and  the  accumulation  of  a  blood-clot.  When  drainage  becomes  necessary 
at  the  primary  operation,  or  if  a  wound  must  be  opened  and  drained  because  of  an 
infection  involving  its  fascial  and  muscular  layers,  the  patient  should  be  kept  on  her 


Fig.  795. — Showing  Operation  for  Hernia  Dovetailing  Rectus  between  the  Broad  Abdominal  Muscles. 

back  in  bed  for  from  one  to  four  weeks  longer  than  is  necessary  after  healing  fer 
prima77i.  A  well  fitted  abdominal  binder  should  be  worn  for  some  months  and  the 
patient  should  be  told  of  the  possibilities  of  a  hernia  after  a  drainage  operation. 

Treatment  of  Post-Operative  Hernia. — The  tendency  of  a  post-operative 
hernia  is  to  increase  in  size  in  spite  of  bandage  or  truss  treatment,  and  for  this  reason 


688 


HERNIA. 


early  operation  is  indicated.  Evidences  of  post-operative  hernia  generally  appear 
within  six  months.  The  hernia  seems  to  grow  larger  and  more  rapidly  in  obese 
women,  probably  because  of  a  greater  intra-abdominal  pressure  due  to  the  relatively 
large  amount  of  intra-abdominal  fat,  and  because  of  the  inabihty  to  apply  an  ab- 
dominal binder  closely  to  the  hernia  opening.  In  such  cases  the  surgeon  may  always 
count  on  the  hernia  having  burrowed  into  the  subcutaneous  fat  to  a  wider  degree 
than  is  apparent  from  the  external  physical  examination.  The  operation  for  post- 
operative hernias  varies  with  the  size,  position,  and  other  characteristics  of  the  hernia, 
and  follows  the  general  principles  advocated  elsewhere  in  this  chapter  for  the  closure 
of  other  hernia  wounds.  If  possible,  the  layers  of  the  abdominal  wall  entering 
into  the  formation  of  the  hernial  ring  should  be  individualized  by  dissection  and 
sutured  separately,  as  in  the  closure  of  a  fresh  abdominal  wound,  overlapping  the 
fascia  when  possible.  In  the  case  of  large  median  hne  hernias  the  overlapping  will 
be  best  accomplished  vertically,  as  in  the  description  for  ventral  hernia.  Hernia 
following  operations  through  the  linea  semilunaris  present  difficulties  because  of  the 

different  directions  of  the  rec- 
tus and  the  oblique  muscles. 
Figs.  795  and  796,  taken  from 
Kelly's  work  on  appendicitis, 
illustrate  the  method  used  in 
closing  such  a  hernia. 

"After  dissecting  out  the 
scar  tissue  the  margin  of  the 
rectus  muscle  is  exposed, 
clean  and  clear,  throughout 
the  entire  length  of  the  wound. 
The  lateral  muscles  are  like- 
wise laid  bare.  The  next  step  is  to  split  the  lateral  muscles,  separating  the 
external  oblique  with  its  stronger  fascia  from  the  internal  oblique  and  the  trans- 
versalis  below.  The  sutures  are  shown  in  full  view  in  Fig.  795,  w^hile  Fig.  796 
exhibits  the  method  of  passing  a  single  suture  in  profile." 


inuous  sutuve  of    Peritoneara 

-Showing   in    Detail   Method    of   Dhawing   Rectus 
BETWEEN  Muscles. 


LUMBAR  HERNIA. 
Most  hernias  of  the  lumbar  region  are  traumatic  in  origin,  following  operations 
or  suppuration.  We  will  speak  of  the  spontaneous  variety  only.  JeanneP  has 
collected  sixty-three  cases  of  lumbar  hernia,  ten  of  which  he  classifies  as  congenital, 
and  fifty-three  as  acquired  hernias.  Formerly  hernias  of  this  region  were  all  sup- 
posed to  protrude  at  the  triangle  of  Petit,  but  in  1866  Grynfeltt^  called  attention  to 
the  triangular  space  of  fascia  immediately  inferior  to  the  twelfth  rib,  which  fascia  is 
covered  by  the  latissimus  dorsi  muscle.  He  considered  this  a  possible  site  of  lumbar 
hernia,  and  shortly  after  Lesshaft,  in  agreeing  with  this  view,  named  the  space  the 

'  Jeannel:  Archives  provinciales  de  Chirurgie,  1902,  tome  xi,  p.  389. 
2Qrynfeltt:    Montpell.  Med.,  1866,  xvi,  329. 


OBTURATOR   HERNIA.  689 

"trigonum  lumbale  superius, "  to  distinguish  it  from  Petit's  triangle,  the  "trigonum 
himbale  inferius."     Jeannel  operated  upon  a  case  presenting  in  this  space. 

Braun  in  1879  showed  by  a  careful  dissection  at  autopsy  in  a  case  of  lumbar 
hernia  that  this  variety  may  find  its  exit  from  a  small  space  immediately  back  of 
Petit's  triangle.  This  opening  penetrates  the  fibrous  ihac  insertion  of  the  latissimus 
dorsi  and  normally  gives  passage  to  the  dorsal  vessels  and  nerves  of  the  buttock. 
Gravitation  abscesses  and  at  times  pus  from  the  pelvic  region  may  find  exit  at  this 
point.  A  review  of  the  literature  seems  to  indicate  that  a  lumbar  hernia  may  pro- 
trude in  either  of  these  regions,  and,  in  fact,  from  any  portion  of  the  quadrilateral 
space  between  the  ribs  and  the  ilium.  Congenital  malformation  or  weakness, 
traumatic  injury  to  the  tissues  of  this  region,  pathologic  changes,  as  from  pelvic 
inflammatory  diseases,  cold  abscesses,  or  caries  of  the  ihum,  or  the  various  paralyses, 
may  determine  the  formation  of  lumbar  hernia.  Abscess  and  lipoma  must  be  con- 
sidered in  making  a  diagnosis.  In  the  treatment,  pads  and  trusses  have  been  worn 
with  more  or  less  satisfaction.  A  number  of  cases  of  strangulation  have  been  re- 
ported and  the  operation  for  non-strangulated  cases  has  been  very  successful. 


OBTURATOR  HERNIA. 
Fortunately,  obturator  hernia  is  rare.  It  is  seldom  that  this  variety  reaches  a 
sufficient  development  to  present  in  a  discoverable  manner,  and  for  this  reason  it  is 
generally  only  after  strangulation  that  a  diagnosis  is  made.  Leaving  the  pelvis 
through  the  obturator  canal,  with  the  obturator  vessels  and  nerve,  the  hernial  sac 
may  be  confined  beneath  the  obturator  externus  and  the  pectineus  muscle,  and  form 
only  a  slight  flat  protrusion ;  or  by  thinning  these  muscles  or  separating  their  fibers  it 
may  work  its  way  forward  and  appear  beneath  the  skin,  in  which  case  it  is  generally 
of  large  size  and  easily  mistaken  for  a  femoral  hernia.  Because  of  the  firm  borders 
of  the  obturator  canal,  it  is  a  favorite  seat  for  hernia  of  the  intestinal  wall,  and  this 
should  always  be  borne  in  mind  in  the  presence  of  symptoms  of  intestinal  obstruction 
with  no  discoverable  cause.  With  the  symptoms  of  intestinal  obstruction,  the 
presence  of  a  flat  tender  swelling  over  the  region  of  the  pectineus  muscle,  and 
flexion  of  the  hip,  strangulated  obturator  hernia  may  be  diagnosed.  In  making  a 
diagnosis  of  obturator  hernia  one  must  exclude  femoral  hernia,  which  is  situated 
above  and  external  to  the  site  of  obturator  hernia.  Lipoma  must  be  excluded. 
Abscesses  arising  within  the  pelvis  or  from  the  bone  may  point  in  the  usual  location 
of  an  obturator  hernia.  The  presence  of  the  Howship-Romberg  symptom  is  im- 
portant. The  terminal  filaments  of  the  anterior  branch  of  the  obturator  nerve  are 
sensory  and  supply  the  skin  over  the  inner  side  of  the  thigh.  Pressure  of  the  hernia 
upon  the  nerves  as  they  both  course  through  the  canal  may  cause  intense  pain  and 
various  paresthesias  referred  to  the  area  supplied  by  the  terminal  sensory  filaments. 
The  hip-joint  is  flexed  and  an  attempt  to  extend  it  is  painful.  If  a  strangulated  ob- 
turator hernia  has  been  diagnosed,  an  incision  is  made  over  the  site  of  the  hernia 
internal  to  the  femoral  vein.  Great  care  should  be  used  in  relieving  the  constriction, 
VOL.  II — 44 


690  HERNIA. 

as  the  obturator  artery  always  lies  close  to  the  neck  of  the  sac,  usually  to  the  outer 
side.  Reduction  has  been  performed  by  stretching  the  obturator  canal  with  the 
fingers.  If  all  the  indications  point  to  a  recent  and  mild  strangulation,  the  bowel 
may  be  replaced,  and  this  followed  by  a  plastic  closure  of  the  external  ring,  using 
great  care  not  to  injure  the  vessels  or  nerves;  but  in  the  majority  of  cases  satisfactory 
examination  and  treatment  of  the  injured  bowel  can  be  obtained  only  by  the  peri- 
toneal route.  An  incision  should  be  made  above  and  parallel  to  Poupart's  ligament 
or  in  the  linea  semilunaris  in  order  to  easily  reach  and  treat  the  internal  ring  of  the 
obturator  canal. 

SCIATIC  HERNIA. 

Hernia  of  the  sciatic  region  may  protrude  through  either  of  three  openings.  If 
it  follows  the  gluteal  artery,  it  leaves  the  great  sacrosciatic  foramen  above  the  pyri- 
formis.  It  may  follow  the  sciatic  artery  and  penetrate  the  same  foramen  below  the 
pyriformis,  or  it  may  leave  the  pelvis  through  the  lesser  sacrosciatic  foramen.  These 
hernias  are  of  extreme  rarity.  They  may  be  confounded  with  certain  perineal  hernias 
which  protrude  back  of  the  rectum  and  appear  below  the  lower  border  of  the  gluteus 
maximus. 

Omentum,  intestine,  ovary,  and  bladder  have  been  found  as  contents  of  sciatic 
hernia.  A  diagnosis  should  be  made  from  lipoma,  abscess,  and  aneurism  of  the 
gluteal  or  sciatic  arteries. 

PERINEAL  HERNIA. 
Under  this  heading  we  exclude  the  ordinary  protrusions  and  prolapses  resulting 
from  the  relaxation  of  the  pelvic  floor  and  ligaments,  and  consider  only  those  cases 
in  which  the  abdominal  or  pelvic  viscera  actually  escape  through  the  pelvic  diaphragm 
and  reach  the  ischiorectal  space.  The  pelvic  diaphragm  is  formed  by  the  funnel- 
shaped  layer  of  muscle  composed  of  the  coccygeus  and  the  iliac  and  pubic  portions 
of  the  levator  ani.  These  muscles  have  reinforcement,  and  their  interspaces  are 
bridged  over  by  the  stronger  superior  and  inferior  pelvic  fascias.  A  perineal  hernia 
escapes  either  between  the  muscle  fibers  or  through  the  interspaces  between  the  in- 
dividual muscles  of  the  pelvic  floor,  and  enters  the  ischiorectal  fossa.  Having  reached 
the  loose  areolar  tissue  of  the  fossa  it  remains  undiscovered,  or  advancing  to  the 
skin,  it  is  recognized  as  an  ischiorectal  hernia;  working  backward,  it  forms  the  so- 
called  rectal  hernia;  pushing  forward,  it  may  appear  under  the  skin  as  a  perineal 
hernia  in  men  or  a  pudendal  hernia  in  women  (Figs.  790,  797,  798).  Either  of  these 
varieties  in  women  may  become  vaginal  hernia,  and  even  carry  the  vaginal  wall  out 
through  the  vulvar  orifice  (prolapse  hernia).  An  anterior  vaginal  hernia  forms  an 
exception  in  that  it  does  not  reach  the  ischiorectal  fossa,  but  escapes  directly  toward 
or  into  the  vagina  by  separating  the  vesico-uterine  tissues.  On  the  other  hand,  a 
hernia  may  separate  the  vesico-uterine  tissues  and  then  make  its  way  laterally  through 
the  levator  ani,  thus  reaching  the  ischiorectal  fossa  and  the  labium.  The  author 
recently  operated  on  such  a  case,  using  both  the  perineal  and  abdominal  routes. 


PERINEAL   HERNIA. 


691 


A  rectal  hernia  may  carry  with  it  a  portion  of  the  bowel  and  cause  a  prolapse  hernia 
analogous  in  its  origin  to  that  of  the  vagina.  Fatal  errors  have  resulted  by  con- 
founding perineal  hernias  with  uterine  polyp  and  pelvic  abscess.  In  addition  to 
these  conditions,  a  diagnosis  must  be  made  from  vaginal  cyst,  prolapse  of  the  vagina, 
cystocele,  and  rectocele.  The  records  of  operative  measures  for  this  condition  are 
very  meager,  but  in  view  of  the  tendency  of  these  hernias  to  increase  in  size,  and 
because  of  the  difficulties  of  treatment  by  supports,  it  would  seem  best  to  resort  to 
the  radical  operation  in  all  favorable  cases.     The  case  is  unfavorable  if  the  pelvic 


'.^'' 


J3,.:Bech^<sr, 
Fig.  797. — Perineal  Hernia. 
Showing  protrusion  of  the  intestinal  contents  into 
the    labium    and     vagina.      Thicke'ning    of     the    skin 
posterior  to  the  commissure.     Johns  Hopkins  Hospital, 
Gyn.  No.  11,385       (Operation  by  H.  A.  Kelly.) 


Fig.   798. — Perineal    Hernia.      Same   as   Fig. 
797,    Showing  the  Sac  Laid  Open. 


muscles  have  been  so  widely  separated  that  a  hernial  ring  cannot  be  palpated.  The 
great  depth  of  the  hernial  ring  from  the  suprapubic  incision  makes  the  perineal 
route  preferable  in  most  cases.  The  perineal  incision  should  be  made  outside  of  and 
parallel  to  the  constrictor  vaginae  muscle.  After  making  the  skin  incision  the  ischio- 
rectal fossa  is  reached  by  blunt  dissection.  If  the  hernia  comes  through  the  posterior 
portion  of  the  levator  ani  muscle,  a  more  liberal  exposure  is  obtained  by  cutting 
through  the  median  end  of  the  transversus  perinei  and  carrying  the  incision  down  to 
the  sphincter  ani.  By  making  use  of  blunt  dissection  in  the  deep  work  it  is  not 
necessarv  to  tie  or  cut  the  vessels  of  the  ischiorectal  region. 


692  HERNIA. 

DIAPHRAGMATIC  HERNIA. 
Diaphragmatic  hernia  usually  occurs  on  the  left  side,  and  the  protrusion  may- 
take  place  through  its  central  tendon,  through  its  muscular  portion,  or  through  any 
of  the  natural  openings  for  the  vessels,  sympathetic  nerves,  or  esophagus.  Many 
diaphragmatic  hernias  are  due  to  arrest  of  development  and  are  not  hernias  in  the 
strict  sense  of  the  term.  By  far  the  largest  number  have  no  sac.  The  diagnosis  is 
rarely  made  intra  vitam.  Gastric  disturbances  with  radiating  pain  in  the  thorax 
may  lead  to  the  finding  of  a  marked  thoracic  displacement  of  abdominal  tympany. 
These  signs,  together  with  a  dextrocardia,  would  be  very  suggestive  of  diaphragmatic 
hernia.  The  condition  is  usually  found  at  autopsy  upon  infants.  In  adults  the 
condition  has  not  been  treated  except  in  the  presence  of  strangulation,  when  the 
practice  has  been  to  perform  a  laparotomy  and  draw  the  viscera  back  into  the  ab- 
domen. With  the  advances  in  thoracic  surgery  it  is  probable  that  such  cases,  when 
a  certain  diagnosis  is  possible,  will  be  treated  through  the  thoracic  wall,  according 
to  the  suggestion  by  Perman.  Rydygier^  gives  the  following  reasons  in  favor  of 
the  thoracic  route:    (1)  an  abdominal  wound  usually  opens  the  pleural  cavity; 

(2)  the  diaphragm  is  more  easily  reached  and  sutured  through  the  thoracic  route; 

(3)  by  opening  the  thorax  the  negative  pressure  of  the  pleural  cavity  is  overcome, 
thus  insuring  the  reposition  of  the  hernia  contents.  A  successful  diaphragm  suture 
is  not  easy,  particularly  if  the  hernial  opening  be  large,  and  it  is  possible  that  the 
silver  filigree  pad  will  become  useful  for  these  cases.  In  view  of  the  large  propor- 
tion of  strangulation  in  diaphragmatic  hernia,  the  radical  treatment  is  indicated  as 
soon  as  a  certain  diagnosis  can  be  made. 


INTERNAL  HERNIA. 

An  internal,  retroperitoneal,  or  intra-abdominal  hernia  is  one  arising  in  one  of 
the  normal  peritoneal  recesses  or  in  a  peritoneal  recess  formed  in  the  course  of  the 
body  development.  In  the  shifting  of  the  gastro-intestinal  canal  from  the  straight 
tube  of  early  fetal  life  to  the  complex  relationships  of  full  development  there  are 
formed  several  folds  and  fossae  which  determine  the  sites  of  internal  hernia. 

In  the  order  of  their  importance  we  may  speak  of:  (1)  hernia  of  the  duodenal 
fossae;  (2)  hernia  of  the  ileocecal  and  retrocecal  recesses;  (3)  hernia  through  the 
foramen  of  Winslow;   (4)  hernia  of  the  intersigmoid  recess;   (5)  retrovesical  hernia. 

Treitz^  first  pointed  out  that  hernias  of  the  duodenal,  cecal,  and  sigmoidal 
regions  possess  sacs  composed  of  tlie  normal  peritoneal  folds  of  these  regions. 

Hernias  of  the  duodenojejunal  region,  commonly  called  Treitz's  hernias,  are 
divided  by  Moynihan^  into  left  and  right  duodenal  hernia.  The  left  duodenal 
hernia,  having  its  origin  in  the  para-duodenal  fossa  (Landzirt)  (see  Fig.  616),  is 
by  far  the  most  common,  more  than  sixty-five  cases  being  referred  to  by  Moynihan. 

'  Rydygier:  "Osteoplastische  Thoracotomie."     ^Treitz:  "  Hernia  retroperitonealis,"  Prag,  1857. 
'  Moynihan  :  "  On  Retroperitoneal  Hernia,"  London,  1906. 


INTERNAL   HERNIA.  693 

The  orifice  is  about  opposite  the  third  lumbar  vertebra  and  is  bounded  by  the 
mesenteric  vein  above  and  to  the  left.  To  the  right  is  the  duodenojejunal  flexure, 
and  inferiorly  the  neck  is  formed  by  the  mesentery  of  the  descending  colon. 

Right  duodenal  hernia^  develops  toward  the  right  and  beneath  the  superior 
mesenteric  artery  or  its  continuation,  the  ileocolic  artery.  Moynihan  collected 
seventeen  cases  of  this  variety.  Waldeyer  first  described  a  fossa  situated  in  the 
mesentery  of  the  upper  part  of  the  jejunum,  and  Brosike  described  the  condition 
in  which  the  jejunum  for  a  greater  or  less  distance  is  adherent  to  the  parietal  wall. 
The  right  duodenal  hernia  dissects  up  the  adherent  jejunum  or  makes  a  sac  in  the 
mesojejunum.  In  either  case  one  leaf  of  the  posterior  peritoneum  is  pushed  toward 
the  right  and  the  sac  dissects  up  the  peritoneum,  and  on  reaching  the  ascending 
colon  displaces  this  toward  the  right  or  dissects  beneath  it,  displacing  it  toward  the 
left. 

The  contents  of  either  a  left  or  right  duodenal  hernia  may  vary  from  a  small 
knuckle  of  bowel  to  the  inclusion  of  the  entire  small  intestine. 

The  symptoms  in  a  chronic  long-standing  case  may  be  those  of  partial  obstruc- 
tion— pain,  indigestion,  and  constipation.  The  acute  cases  are  marked  by  the 
usual  symptoms  of  acute  intestinal  obstruction,  and  should  the  sac  contain  a  large 
part  of  the  small  bowel  a  probable  diagnosis  is  possible;  for  in  addition  to  the  pain, 
obstipation,  vomiting,  and  collapse,  a  localized  tumor  may  be  outlined.  This  is 
characterized  by  its  rounded  outline,  tense  cystic  to  solid  feel,  partial  mobility, 
tympanitic  percussion  note,  and  intestinal  sounds  on  auscultation.  In  addition, 
if  the  hernia  be  left  duodenal,  the  compression  of  the  inferior  mesenteric  vein  may 
result  in  hemorrhoids  and  rectal  bleeding  and  the  development  of  collateral  circula- 
tion through  the  superficial  abdominal  veins. 

2.  Hernia  of  the  ileocecal  and  retrocecal  recesses.  Fig.  799  illustrates  in  a 
graphic  manner  the  folds  and  fossae  of  the  ileocecal  region.  Moynihan  collected 
seven  cases  of  hernia  of  the  ileoappendicular  or  ileocecal  fossa;  and  of  the  sixteen 
cases  reported  of  the  retrocolic  variety,  he  considers  but  seven  as  well  authenticated. 
In  none  of  these  cases  was  there  any  considerable  amount  of  bowel  incarcerated, 
there  being  usually  only  a  loop  of  ileum,  and  in  the  operative  cases  this  was  easily 
reduced. 

3.  Hernia  into  the  foramen  of  Winslow  is  said  to  occur  only  under  the  following 
conditions:  (a)  when  there  is  a  common  mesentery  for  the  whole  intestine;  (b) 
in  the  absence  of  the  secondary  fusion  of  the  ascending  colon  to  the  posterior  ab- 
dominal wall;  (c)  with  an  abnormally  large  size  of  the  foramen  of  Winslow;  (d) 
with  an  abnormal  length  of  the  mesentery,  and  consequently  undue  mobility  of 
the  intestine.  Twelve  cases  are  recorded,  the  majority  of  these  involving  the  small 
intestine.  In  Moir's  case  the  entire  small  bowel  was  found  in  the  lesser  cavity, 
and  in  Treves'  case  the  cecum,  the  ascending  colon,  and  a  portion  of  the  transverse 
colon  had  entered  the  foramen  of  Winslow. 

The  diagnosis  of  hernia  into  the  lesser  cavity  should  be  suspected  if  with  the 
^Waldeyer:  "Hernia  mesenterico-parietalis,"  Brosike,  Berlin,  1891. 


694 


HERNIA. 


signs  of  acute  intestinal  obstruction  there  is  unusual  pain  in  the  epigastrium  and  a 
tympanitic  tumor  in  this  region. 

4.  Moynihan  accepts  but  two  of  the  reported  cases  of  intersigmoid  hernia. 

5.  Sultan  mentions  four  of  the  retrovesical  variety. 

^Ye  have  not  classified  as  retroperitoneal  hernia  those  cases  of  mesentery  openings 
with  penetrating  bowel.  Akerman^  reports  such  a  case  as  an  intra-abdominal 
hernia  and  collects  the  literature  on  the  subject.     His  patient  was  operated  upon 


2..  Superior    ileo 

-cecal   fossa 

3.  JnferioT  i  Uo-cecaLfossa  (interria.1  rstro-colic) 

t.  Lower  portion  of  same  (  •       •           » -ceealj 

5.  External    retro 

-cecal  fossa 

G.     » 

-colic        ' 

/ 

a.  jleo-coUc    Told 
b      '■     -cecal     « 
c.     Mesappendix 

f  Retro-coUc    fold 

AnT^' 


Fig.  799. — The  Folds  and  Foss^  of  the  Ileocecal  Region. 

The  cecum  is  lifted  up  out  of  its  bed  in  the  iliac  fossa,  exposing  the  retrocecal  folds  and  fossae.     The  appendix 

has  been  drawn  out  of  the  ileocecal  fossa  to  show  the  mesappendix. 

because  of  long-standing  symptoms,  and  an  hour-glass  stomach  adherent  to  the 
left  lobe  of  the  liver  was  found.  There  was  a  large  hole  in  the  transverse  meso- 
colon, through  which  penetrated  a  large  portion  of  the  small  intestine.  Three 
similar  cases  were  known  to  Treitz,^  and  he  considers  the  mesenteric  openings  to 
be  secondary  to  the  pathologic  process  in  the  stomach.     As  Treves^  pointed  out, 

^  Akerman  :    "  Intraabdominaler  Bruch  durch   eine  Offnune:  im  Mesocolon  transversum," 
Nordiskt  Medicinskt  Arkiv,  August,  1902,  Haft  2,  No.  9. 

2  Treitz  :  Ibid.,  p.  95.  ^  Treves  :  Hunterian  Lectures,  Brit.  Med.  Jour.,  1885,  1,  471. 


INTERNAL   HERNIA.  695 

the  most  frequent  site  of  such  openings  is  the  mesentery  of  the  ileocecal  region ;  and 
this  corresponds  with  Treitz's  theory  of  an  inflammatory  basis.  The  bowel  which 
passes  through  these  openings  is  generally  without  a  special  covering,  and  for  this 
reason,  and  because  of  the  probable  pathologic  origin  of  the  opening,  we  question 
whether  such  misplacements  should  be  called  hernias. 

Treatment. — Attention  will  rarely  be  called  to  internal  hernia  except  for  the 
incidence  of  strangulation.  Manski^  found  that  strangulation  occurred  in  about 
20  per  cent,  of  all  cases.  Fortunately  the  obstruction  is  due  in  many  of  these  cases 
to  a  volvulus  of  the  bowel  rather  than  to  compression  at  the  neck  of  the  sac.  If 
the  bowel  is  not  easily  reduced  by  traction,  one  may  try  to  enlarge  the  neck  by 
gradual  stretching  with  the  fingers.  If  a  non-vascular  area  can  be  found  in  the 
neck  of  the  sac,  careful  cutting  with  the  knife  or  scissors  will  aid  in  the  dilatation. 

In  case  of  failure  to  reduce  the  bowel  Moynihan  suggests  the  incision  of  the  sac 
through  a  non-vascular  area  in  the  mesentery  in  case  of  a  duodenal  hernia,  or 
through  the  gastrocolic  or  gastrohepatic  omentum  in  the  case  of  hernia  into  the 
lesser  cavity.  The  bowel  may  be  delivered  through  this  incision  and  the  volvulus 
straightened.  If  reduction  is  still  impossible,  the  dilated  bowel  may  be  incised 
and  emptied,  and  after  suture  it  should  be  easily  reducible. 

After  finding  and  relieving  a  strangulation  in  one  of  these  pockets,  the  question 
of  dealing  with  the  hernial  sac  and  the  site  of  strangulation  can  only  be  settled  by 
the  circumstances  of  each  case.  Often  it  will  be  wise  after  the  relief  of  the  strangula- 
tion to  ignore  the  sac  and  the  orifice.  Suture  of  the  ring  may  present  at  least  two 
dangers:  first,  since  most  of  these  hernias  are  of  the  duodenojejunal  fossa,  the 
suture  might  involve  the  inferior  mesenteric  vessels;  second,  closure  of  the  hernial 
sac  might  give  origin  to  a  large  peritoneal  cyst.  Intelligent  packing  with  gauze  may 
be  of  service  in  obliterating  the  peritoneal  pocket. 

^Manski:  Miinchener  med.  Wochenschr.,  1893,  xl,  S.  4.35  u.  454. 


CHAPTER  XLI. 

OPERATIONS  FOR  INGUINAL  HERNIA. 
By  Edward  Martin,  M.D. 

Historical. — The  ground  has  been  adequately  traversed  by  Hunner  (Chapter 
XL),  who  justly  awards  to  Marcy  the  large  measure  of  credit  due  him  for  reviv- 
ing the  operation  of  radical  cure,  described  and  practised  many  centuries  before. 

Definition. — An  inguinal  hernia  is  an  abnormal,  recurring,  or  permanent 
visceral  protrusion  in  the  inguinal  region  wholly  or  partly  invested  with  the  parietal 
peritoneum. 

The  peritoneal  investment  of  the  lower  portion  of  the  anterior  abdominal  wall, 
viewed  from  behind  forward,  is  raised  into  a  series  of  folds.  The  central  fold  pass- 
ing directly  upward  from  the  bladder  fundus  is  caused  by  the  obliterated  urachus. 
On  either  side  lie  the  folds  of  the  obliterated  hypogastric  arteries.  To  the  outer 
side  of  the  obliterated  hypogastric  arteries,  and  corresponding  to  the  position  of  the 
inner  border  of  the  internal  ring,  about  midway  between  the  anterior  superior 
spinous  processes  of  the  ilium  and  the  symphysis  pubis,  lie  the  folds  indicating 
the  position  of  the  deep  epigastric  arteries. 

Bounded  by  these  folds  or  thickened  bands  laterally  and  by  Poupart's  ligament 
below  are  fossae,  or  areas  predisposed  to  yielding  should  there  be  abnormal  intra- 
abdominal pressure. 

The  depression  at  the  outer  side  of  the  deep  epigastric  artery  is  called  the  ex- 
ternal inguinal  fossa;  in  this  fossa  lies  the  internal  ring,  a  parietal  opening  through 
the  muscles  and  fascia  left  by  the  descent  of  the  testis,  and  occupied  by  the  vas  and 
the  vessels  and  nerves  of  the  cord.  From  this  fossa  projects  the  peritoneal  pouch 
which  precedes  or  accompanies  the  testicle  in  its  descent  from  its  position  below  the 
kidney  into  the  scrotum,  and  which,  though  it  normally  becomes  obliterated  except 
for  that  part  forming  the  tunica  vaginalis  testis,  often  remains  patulous  in  its  upper 
part,  predisposing  to  the  development  of  hernia.  A  hernia  developing  in  the  ex- 
ternal iliac  fossa  is  called  oblique. 

The  depression  to  the  inner  side  of  the  deep  epigastric  artery,  lying  directly 
behind  the  external  ring,  is  called  the  internal  inguinal  fossa.  A  hernia  developing 
in  this  fossa  is  called  direct.  The  hernial  projection  usually  develops  to  the  outer 
side  of  the  obliterated  hypogastric  artery;  exceptionally  it  projects  to  the  inner  side 
of  this  band,  between  it  and  the  outer  border  of  the  rectus  muscle. 

A  hernia  which  begins  in  the  external  iliac  fossa,  i.  e.,  to  the  outer  side  of  the 
deep  epigastric  artery,  before  it  becomes  subcutaneous,  must  pass  downward,  and 
inward  along  the  inguinal  canal  (2  to  5  cm.),  then  downward,  outward,  and  forward, 

696 


THE   VARIETIES    OF   INGUINAL   HERNIA.  697 

pushing  before  it  the  intercolumnar  fascia.  There  is  thus  mechanically  afforded  a 
valvular  protection  against  the  development  of  indirect  inguinal  hernia  so  efficient 
that  the  best  designed  and  most  successful  operations  of  radical  cure  are  those 
having  for  their  end  the  reproduction  and  maintenance  of  these  conditions. 

The  mechanical  obstacles  to  the  formation  of  an  oblique,  complete  inguinal 
hernia  in  the  person  of  a  healthy,  well-developed  man  are  so  great  that  it  is  difficult 
to  imagine  such  a  condition  in  the  absence  of  a  congenital  predilection  in  the  form 
of  a  peritoneal  pouch  left  as  a  remnant  after  the  descent  of  the  testicle,  nor  is  there 
clinical  evidence  wanting  to  show  that  the  vast  majority  of  oblique  inguinal  hernias 
developing  in  children  and  young  men  are  dependent  upon  such  a  condition. 

Direct  inguinal  hernia  projecting  through  the  internal  inguinal  fossa  is  due  to 
the  gradual  yielding  of  the  fascial  parietes  (conjoined  tendon)  to  the  inner  side  of 
the  deep  epigastric  artery.  When  an  oblique  hernia  has  lasted  for  a  long  time  and 
has  reached  considerable  size,  by  dragging  on  its  neck  it  pulls  the  inner  opening 
so  directly  behind  the  external  ring  that  the  distinction  between  a  direct  and  an 
indirect  hernia  can  be  made  only  by  finding  the  pulsation  of  the  deep  epigastric 
artery. 

The  Varieties  of  Inguinal  Hernia. — The  principal  varieties  are  the  external 
or  the  oblique,  and  the  internal  or  direct. 

The  external  or  oblique  is,  as  has  been  noted,  usually  dependent  for  its  develop- 
ment upon  a  persistent  patulous  condition  of  the  peritoneal  pouch  which  accom- 
panies the  testicle  in  its  descent.  When  this  pouch  remains  completely  open  down 
to  the  testicle,  the  condition  resulting  from  the  descent  of  viscera  into  this  pouch 
is  called  congenital  hernia.  If  this  peritoneal  pouch  is  closed  at  its  lower  point 
only,  i.  e.,  above  the  testicle,  the  descent  of  intestine  into  it  forms  a  hernia  of  the 
funicular  process.  When  the  pouch  is  closed  at  the  internal  ring,  remaining 
patulous  in  the  rest  of  its  course,  there  may  develop  either  the  infantile  or  the 
encysted  hernia.  In  the  former  a  sac  is  formed  from  the  neighborhood  of  the 
internal  ring  and  descends  behind  the  patulous  vaginal  tunic.  Thus  in  reaching 
the  hernial  sac  three  layers  of  peritoneum  must  be  traversed,  i.  e.,  two  of  the  vaginal 
tunic  and  one  of  the  sac  proper.  In  the  encysted  form  of  hernia  the  sac  bulges 
into  the  vaginal  tunic,  thus  necessitating  the  traversing  of  two  layers  of  peritoneum 
before  entering  the  hernial  sac. 

The  hernia  is  called  complete  or  incomplete  in  accordance  with  whether  it  does 
or  does  not  project  from  the  external  ring.  In  the  latter  case  it  is  often  called 
bubonocele. 

Of  the  incomplete  inguinal  hernias,  those  dependent  upon  congenital  diverticula 
and  often  associated  with  testicular  ectopy  are  particularly  important  because  of 
the  danger  of  strangulation. 

The  hernial  sac  in  the  case  of  oblique  inguinal  hernia,  either  developing  in 
infancy  or  later  in  life,  as  the  result  of  a  persistent  patulous  condition  of  the  upper 
part  of  the  funicular  process  of  the  peritoneum,  lies  within  the  proper  tunic  of  the 
cord  and  in  its  development  passes  into  the  scrotum.     It  lies  usually  in  front  of 


698  OPERATIONS    FOR   INGUINAL   HERNIA. 

the  cord  with  the  veins  of  the  latter  intimately  adherent  and  spread  about  it.  It 
may  exhibit  diverticula,  valvular  folds,  or  irregular  seats  of  constriction.  The 
diverticula  at  times  may  be  as  large  or  even  larger  than  the  more  conspicuous  sac, 
passing  from  the  internal  ring  between  the  peritoneum  and  trans  versahs  fascia  in  any 
direction,  and  in  case  of  strangulation  or  incarceration  misleading  the  surgeon  in 
regard  to  the  completeness  of  reduction  (properitoneal  hernia).  Diverticula  passing 
between  the  muscular  layers  are  termed  intraparietal;  those  projecting  between 
the  subcutaneous  and  deep  fascia  are  called  superficial. 

The  sac  of  the  direct  inguinal  hernia  is  placed  to  the  inner  side  of  the  cord,  and 
though  its  coverings  are  practically  the  same  it  does  not  usually  become  scrotal. 

The  sac  usually  contains  omentum  and  the  small  intestine.  Upon  the  right 
side  the  appendix  and  cecum  are  frequently  found,  the  latter  sometimes  lying  com- 
pletely within  the  sac;  often,  however,  only  partly  covered  by  peritoneum,  the  whole 
mesenteric  attachment  having  been  dragged  downward.  Under  such  circumstances 
the  sac  is  an  incomplete  one.  The  bladder  has  also  occasionally  been  found  as  a 
part  of  the  hernial  projection,  rarely  with  a  complete  peritoneal  investment.  On 
the  left  side  a  portion  of  the  sigmoid  flexure  may  form  a  part  of  the  hernial  contents, 
either  a  free  loop  passing  into  the  hernial  sac  or,  from  sliding  of  its  mesenteric 
attachment,  the  bowel  being  but  partly  covered  by  the  hernial  sac. 

In  size  the  hernia  may  vary  from  that  of  the  last  joint  of  the  little  finger,  to  be 
detected  only  by  careful  examination,  to  that  of  a  keg  or  small  barrel  containing 
the  greater  part  of  the  abdominal  viscera. 

Symptoms  of  Inguinal  Hernia. — Symptoms  of  uncomplicated  inguinal  hernia 
vary  from  none  at  all,  with  the  exception  of  a  lump  in  the  groin  which  comes  and 
goes,  to  recurring  pain  of  such  intensity  as  to  amount  to  complete  disability. 

Usually  there  is  a  sense  of  discomfort  and  weakness  in  the  region  of  the  groin, 
aggravated  by  lifting,  coughing,  or  abdominal  strain,  associated  with  intestinal  indi- 
gestion. There  is  a  tumor  which  disappears  on  lying  down,  becomes  obvious  on 
standing,  and  prominent  and  tense  on  suddenly  increased  intra-abdominal  pressure, 
as  by  coughing,  straining,  or  lifting.  This  tumor  is  best  located  by  invaginating  the 
scrotum,  with  the  little  finger  in  the  case  of  children,  passing  the  tip  of  the  latter  as 
far  as  practicable  through  the  external  abdominal  ring.  Crying  efforts  then  give 
to  the  finger-tip  the  sense  of  a  soft  jar  as  the  viscus  contained  in  the  hernial  sac  is 
forced  down.     Thus  may  be  detected  hernias  in  their  beginning. 

In  excessively  fat  people  the  detection  of  a  hernia  may  be  difficult,  indeed  quite 
impossible,  since  it  has  happened  that  even  when  strangulation  has  developed  the 
most  careful  search  in  the  inguinal  region  apparently  excluded  hernia  as  the  cause 
of  the  trouble,  though  subsequent  abdominal  section  demonstrated  a  loop  of  gut 
gangrenous  from  constriction  of  the  internal  ring. 

Irreducible  omental  hernia,  which  may  reach  large  size,  simulates  so  closely 
lipoma — which  indeed  it  is — that  the  distinction  cannot  be  made  in  the  absence 
of  a  history,  though  the  tracing  of  a  thick  pedicle  through  the  inguinal  canal  into 
the  abdominal  cavity  will  strongly  suggest  that  the  growth  has  a  hernial  origin. 


TREATMENT    OF   HERNIA.  699 

Moreover,  lipoma  of  large  size,  except  that  due  to  a  herniated  omentum,  is  rare  in 

this  region. 

The  distinction  of  hernia  from  hydrocele  is  based  on  a  pronounced  translucency 
of  the  latter,  a  single  sign  which  must  not  be  depended  upon  too  absolutely  in  the 
case  of  infants,  since  a  strong  electric  light  will  give  a  very  fair  degree  of  trans- 
lucency in  the  case  of  congenital  hernia  made  up  of  small  gas-distended  intestines 
and  the  feathery  omentum  characteristic  of  early  life. 

Some  funicular  hydroceles  can  be  apparently  traced  along  the  inguinal  canal 
into  the  peritoneal  cavity  and  give  an  impulse,  though  not  an  expansile  one,  on 
coughing.  They  are  dull  on  percussion,  extremely  translucent  to  transmitted 
light,  give  no  gurgling,  are  in  reality  irreducible,  though  they  may  be  pressed  up 
into  the  inguinal  canal  and  are  not  subject  to  sudden  pronounced  changes  in  size 
incident  to  alterations  in  intra-abdominal  pressure.  In  infants  such  hydroceles 
are  not  infrequently  combined  with  hernia. 

Conditions  Predisposing  to  Inguinal  Hernia.— Inguinal  hernia,  the  com- 
monest of  all  forms  of  hernia,  exhibits  its  greatest  percentage  of  incidence  in  male 
infants  and  middle-aged  men.  There  is  no  doubt  that  a  persistently  patulous  con- 
dition of  the  peritoneal  pouch  is  an  almost  invariable  predisposing  factor  to  the 
oblique  inguinal  hernias  of  infants  and  children  and  the  usual  favoring  condition 
when  similar  hernias  develop  in  the  adult.  Other  predisposing  factors  are  an 
unusually  narrow  origin  of  the  internal  oblique  muscle  from  Poupart's  Hgament 
(Ferguson)  and  the  presence  of  properitoneal  lipomata  or  fat  masses  in  the  inguinal 
region. 

Direct  inguinal  hernia  is  due  to  the  failure  upon  the  part  of  the  fascia  to  with- 
stand intra-abdominal  pressure;  hence  sufficient  predisposition  to  it  is  dependent 
upon  all  those  causes  which  increase  intra-abdominal  pressure,  such  as  obesity, 
ascites,  chronic  and  harassing  cough,  or  the  straining  of  frequently  recurring  or  diffi- 
cult defecation  or  urination;  associated  with  muscular  and  fascial  degeneration. 

These  direct  hernias  are  often  double  and  bilateral.  The  hernia,  if  unilateral, 
is  commonly  on  the  right  side;  if  bilateral  it  is  usually  larger  on  the  right  than  on 
the  left  side. 

Treatment  of  Hernia.— Prophylaxis,  in  so  far  as  the  adult  is  concerned,  prob- 
ably Hes  in  the  cure  by  operation  of  hernias  occurring  in  infants.  So  many  of 
these,  however,  recover  with  a  simple  truss  that  until  the  results  of  prolonged  clinical 
study  are  available  the  possibility  of  many  of  the  oblique  inguinal  hernias  of  the 
adult,  especially  those  of  slow  formation,  being  due  to  imperfecdy  cured  hernias  in 
infancy  stands  on  theoretic  considerations  rather  than  on  the  results  of  accurate 
observations. 

Since,  even  with  the  formation  predisposing  to  their  development,  hernias  depend 
upon  the  failure  of  the  musculo-fascial  abdominal  investment  to  resist  intra-abdomi- 
nal pressure,  it  is  obvious  that  whatever  tends  to  strengthen  this  investment  will  lessen 
the  likelihood  of  hernia,  and  that  whatever  has  the  effect  of  increasing  either  the 
frequency  or  the  violence  of  intra-abdominal  pressure  will  have  the  contrary  effect. 


700  OPERATIONS    FOR   INGUINAL   HERNIA. 

Exercises  for  the  development  of  the  abdominal  muscles  and  for  their  mainte- 
nance in  a  healthy  condition  are  particularly  to  be  commended  to  middle-aged 
men  of  sedentary  habit,  with  large  external  rings,  pendulous  belHes,  and  hereditary 
predisposition  to  hernia. 

The  affection  once  developed,  the  treatment  should,  as  a  rule,  be  operative. 
This  treatment  becomes  imperative  when  the  hernia  is  compHcated  by  incarceration, 
strangulation,  recurrent  inflammation,  persistent  pain,  or  crippled  intestinal  indiges- 
tion. 

The  operation  is  advisable  in  all  healthy  children  past  the  age  of  two  years  in 
whom  a  truss  has  not  been  curative,  and  in  all  vigorous  adults  in  whom  the  hernia 
cannot  be  completely  or  comfortably  retained  by  a  truss. 

Old  arteriosclerotic  men  having  visceral  disease,  and  having  large  hernias  and 
flabby  parietes,  should  not  be  subjected  to  operation  in  the  absence  of  comph- 
cations  which  make  this  absolutely  necessary. 

Preparation  for  Operation. — Where  practicable,  for  three  days  before  operation 
the  patient  should  be  fed  moderately  on  a  mainly  nitrogenous  diet,  such  as  leaves 
but  a  small  debris;  should  have  his  bowels  opened  regularly  by  mild  laxatives,  if 
these  be  indicated,  not  by  active  purgatives,  and  should  take  an  intestinal  antiseptic. 
The  best  is  5  grains  of  betanaphthol  bismuth  four  times  daily.  The  kidneys  should 
be  induced  to  secrete  freely,  nor,  if  there  be  a  choice,  should  the  operation  be  per- 
formed in  the  presence  of  a  bronchitis  or  any  pulmonary  complication.  The  night 
before  operation  the  patient  is  given  a  general  bath,  the  area  of  operation  is  shaved  and 
cleansed,  the  skin  being  not  in  the  least  irritated,  and  is  protected  by  a  spica  bandage 
holding  in  place  a  dressing  of  sterile  gauze.  This  dressing  is  repeated  the  morning 
before  operation. 

Anesthesia. — In  the  majority  of  robust  patients  the  anesthetic  of  choice  is  nitrous 
oxid  followed  by  ether,  given  by  a  skilled  anesthetist.  When  an  inexperienced 
resident  only  is  available,  local  anesthesia  is  to  be  preferred;  the  latter,  as  a  rule,  in 
the  elderly  and  infirm,  those  suffering  from  pulmonary  complications  and  visceral 
disease  or  profoundly  exhausted  by  the  effects  of  the  complications  of  strangulation. 

Local  anesthesia  is  feasible  in  all  cases,  but  is  difficult  of  successful  application 
in  the  fat  and  the  highly  neurotic.  Gushing^  advised  infiltration  of  the  fine  of  inci- 
sion with  Schleich's  cocain  solution,  followed  by  immediate  incision.  He  states 
that  efforts  to  anesthetize  the  subcutaneous  fat  are  futile.  If  the  incision  through- 
out its  whole  length  is  carried  down  to  the  aponeurosis,  unanesthetized  fibers  of  the 
iliohypogastric  will  be  encountered  in  the  superficial  fat  at  the  lower  angle,  together 
with  one  or  two  large  veins,  division  of  which  is  painful.  Therefore  the  cut  is 
deepened  only  at  its  upper  angle;  the  aponeurosis  of  the  external  oblique  is  then 
opened  in  the  line  of  fibers  from  the  external  ring,  and  the  iliohypogastric  and  ingui- 
nal nerves  are  immediately  cocainized  with  a  1  per  cent,  cocain  solution  as  they 
lie  under  it.     After  this  procedure  the  lower  angle  of  the  incision  may  be  painlessly 

^  Gushing,  Harvey:  "The  Employment  of  Local  Angesthesia  in  the  Radical  Cure  of  Certain 
Cases  of  Hernia,"  Ann.  Surg.,  Jan.,  1900,  xxxi,  1. 


TREATMENT   OF   HERNIA. 


701 


deepened  to  the  external  ring,  and  the  interculumnar  fibers  of  the  aponeurotic  inser- 
tion divided.  If  the  fibers  of  the  internal  obUque  are  to  be  cut,  preliminary  cocaini- 
zation  of  the  edge  of  the  muscles  is  necessary.  The  combined  ilio-inguinal  and 
genital  branch  having  been  cocainized,  it  is  reflected  to  one  side,  since  its  incision 
leads  to  more  or  less  paralysis  of  the  cremaster  muscle.  The  exposure  of  the 
sac  and  cord  after  a  longitudinal  division  of  the  infundibuliforra  fascia,  the  amputa- 


Intern.obliaue 


N(?cko[  sac  covered  'by 
mfundib,  fascia  and 
cremasterfibres. 


aJ/er'V'^ri/ej'  {"usl/r/f^ 


Fig.  800. — Showing  Usual  Situation  of  Nerves  as  Exposed  after  Reflection  of  the  Divided  Aponeu- 
rosis  (Harvey  Gushing). 

tion  of  the  sac  at  its  neck,  the  closure  of  the  peritoneal  opening,  the  excision  of  the 
fundus  of  the  sac,  division  of  the  cord,  and  castration,  if  deemed  advisable,  may 
now  be  done  practically  without  pain.  Occasionally  some  stray  fibers  of  the  genito- 
crural  may  be  encountered  about  the  neck  of  the  sac  which  may  require  further 
infiltration. 

Gushing  notes  that  more  time  is  consumed  in  the  operation,  and  it  is  undoubt- 


702  OPERATIONS    FOR   INGUINAL   HERNIA. 

edly  the  case  that  careful  dissection  must  take  the  place  of  rough  stripping.     This, 
however,  is  not  a  disadvantage. 

Bodine,'  as  the  result  of  his  experience  of  several  hundred  cases,  has  become  an 
enthusiastic  convert  to  the  method.  He  uses  a  0.2  per  cent,  solution  of  cocain  for 
infiltration  of  the  skin  and  nerve-trunks.  Elsewhere  a  solution  of  one-half  this 
strength.  He  infiltrates  the  margins  of  the  internal  ring  and  also  the  fine  of  incision 
through  the  tissues  covering  the  hernial  sac  and  the  neck  of  the  latter. 

In  the  choice  of  the  local  anesthetic  eucain  is  to  be  preferred  to  cocain,  since  it  is 
only  one-fifth  as  toxic  and  can  be  sterilized  by  boiling.  Its  benumbing  effect  is, 
however,  more  transitory. 

Operation. — The  operation  varies  in  accordance  with  the  conditions  encountered. 
When  the  hernia  is  due  to  a  patulous  condition  of  the  funicular  peritoneal  process, 
unless  it  has  been  of  such  long  standing  as  materially  to  widen  the  internal  ring 
and  atrophy  the  surrounding  muscles  and  fascia  by  pressure,  all  that  is  needful 
for  cure  is  isolation  of  the  sac,  ligature  of  the  neck,  suture  of  the  internal  oblique 
muscle  to  Poupart's  ligament,  and  closure  of  the  wound  with  as  little  disturbance 
of  tissue  as  possible.  When,  however,  the  hernia  is  of  great  size  and  long  standing, 
even  though  it  be  oblique,  it  will  have  so  materially  weakened  the  posterior  wall  of 
the  inguinal  canal  that  an  operation  designed  for  the  strengthening  of  this  region 
will  be  needful. 

In  the  case  of  direct  hernias,  the  necessity  for  strengthening  the  abdominal  wall 
will  always  be  present. 

In  children  with  a  well-developed  musculature  and  a  scrotal  hernia  protruding 
through  a  small  internal  ring  the  operation  consists  of  a  short  incision  over  the 
inguinal  canal,  free  exposure  of  the  latter  by  spKtting  the  fibers  of  the  external  obHque, 
separation  of  the  sac  up  to  the  internal  ring,  twisting  and  Hgation  of  the  sac 
and  its  removal,  unless  it  be  total,  in  which  case  a  portion  sufficient  to  serve  as  a 
tunica  vaginalis  testis  is  allowed  to  remain.  The  internal  oblique  is  stitched  down 
to  Poupart's  ligament  by  one  or  two  sutures,  the  cord  not  being  disturbed.  The 
external  oblique  is  closed  by  overlapping.^  In  hernia  compHcated  by  undescended 
testicle  a  free  division  of  ^ill  the  structures  of  the  cord,  with  the  exception  of  its  blood- 
supply,  may  enable  the  testicle  to  be  brought  into  the  scrotum;  if  this  is  evidently 
impossible,  the  testes  can  be  pushed  back  into  the  pelvis,  the  sac  being  dissected 
free  and  closed. 

When  the  sac  communicates  with  the  general  peritoneal  cavity  by  a  wide  open- 
ing, incident  either  to  congenital  muscular  deficiency  or  to  pressure  atrophy,  a  more 
elaborate  procedure  is  needful. 

'  Bodine,  John  A.:  "A  Plea  for  Local  Anesthesia  in  the  Radical  Cure  of  Inguinal  Hernia," 
Med.  Rec,  Oct.  21,  1905,  Ixviii,  p.  645. 

^  Lucas-Championniere,  Just.:  "Cure  Radicale  de  la  Hernia  Inguinale,"  April,  1901, 
Andrews,  E.  Wyllys:  "Past  and  Present  Obstacles  to  the  Radical  Cure  of  Hernia,  with  Demon- 
strations," Jour.  Am.  Med.  Assoc,  1897,  xxviii,  868.  Noble,  Charles  P.:  _  "Overlapping  the 
Aponeuroses  in  Closure  of  Wounds  of  the  Abdominal  Wall,  including  Umbilical,  Ventral,  and 
Inguinal  Hernise,"  Ann.  Surg.,  1906,  xliii,  349. 


TREATMENT   OF    HERNIA. 


703 


Halsted/  who  has  done  more  than  any  one  man  to  popularize  the  radical  cure 
of  hernia  by  showing  its  safety  and  efficiency,  thus  describes  the  operation : 

"The  aponeurosis  of  the  external  oblique  muscle  is  divided  and  the  two  flaps 
reflected  as  in  the  Bassini-Halsted  operation. 

"The  cremaster  muscle  and  fascia  is  split,  not  directly  over  the  center  of  the  cord, 
but  a  little  above  it. 

"The  internal  oblique  muscle  is  made  as  free  as  possible.  A  little  artefaction 
is  here  often  necessary.  If  the  muscle  cannot  be  drawn,  without  tension,  well  down 
to  Poupart's  ligament,  it  helps,  I  think,  to  make  a  relaxation  cut  or  two  in  the  an- 
terior sheath  of  the  rectus  muscle  under  the  aponeurosis  of  the  external  oblique 
muscle  (Fig.  801). 
This  sheath  being 
in  part  the  aponeu- 
rosis of  the  internal 
oblique  muscle,  one 
can  readily  compre- 
hend that  incisions 
into  it,  if  properly 
made,  might  be  of 
service.  It  is  well, 
however,  to  post- 
pone making  such 
incisions  until  the 
sewing  of  the  inter- 
nal oblique  muscle 
to  Poupart's  liga- 
ment is  begun,  for 
then  the  amount 
of  tension  can  be 
nicely  gauged  and 
the  number,  length, 
and  precise  position 

of  the  relaxation  cuts  determined.  A  second  reason  for  postponing  the  relaxation 
incisions  into  the  anterior  sheath  of  the  rectus  muscle  is  that  we  sometimes  use 
this  portion  of  the  rectus  sheath  to  close  the  lower  part  of  the  inguinal  canal. 

"When  the  veins  are  large,  and  this  is  usually  the  case,  they  should  be  excised 
with  very  great  care  to  avoid  even  the  slightest  extravasation  of  blood  into  the  tis- 
sues about  the  smaller  veins  and  about  the  vas  deferens  which  they  accompany. 
And  the  vas  deferens,  as  first  emphasized  by  Bloodgood,  should  not  be  raised  from 
its  bed  or  handled  or  even  touched,  lest  thrombosis  of  its  veins  occur.  The  veins 
should  be  ligated  as  high  up  in  the  abdomen  as  possible,  being  pulled  down  quite 

'  Halsted,  Wm.  S. :  "The  Cure  of  the  More  Difficult  as  Well  as  the  Simpler  Inguinal  Ruptures," 
Johns  Hopkins  Hosp.  Bull.,  Aug.,  1903,  vol.  xiv,  No.  149,  p.  208. 


Fig.  SUl. — Halsted's  Operation. 
Showing  relaxation  cut  in  the  anterior  sheath  of  the  rectus  muscle. 


ro4 


OPERATIONS    FOR   INGUINAL   HERN^A. 


firmly  just  before  the  ligature  (in  a  needle  with  the  blunt  end  first)  is  passed  between 
them.  As  a  precaution  against  slipping,  we  apply  two  ligatures  of  fine  silk,  both 
for  the  abdominal  stump  and  for  the  testicle  stump  of  the  veins.  The  farther  from 
the  testicle  the  veins  are  divided,  the  better,  provided,  of  course,  that  their  stump  is 
external  to  the  external  abdominal  ring. 

"Ligation  of  the  sac  is  made  by  transfixion  or  by  purse-string  suture  at  the 
highest  possible  point.  Both  ends  of  this  suture,  after  tying,  are  threaded  on  long 
curved  needles,  then  carried  far  out  under  the  internal  oblique  muscle  from  behind 


Fig.   802. — Halsted's  Operation. 
Exposure  of  the  sac,  the  vas,  and  the  spermatic  veins. 

forward,  and,  passing  through  this  muscle,  about  5  mm.  apart,  are  tied.  The  idea 
was  suggested  to  the  author  by  Kocher's  operation,  the  principle  being  essentially 
the  same. 

"The  lower  flap  of  the  cremaster  muscle  and  its  fascia  is  drawn  up  under  the 
mobilized  internal  oblique  muscle  and  held  in  this  position  by  very  fine  silk  stitches, 
which,  having  engaged  firmly  a  few  bundles  of  the  cremaster,  perforate  the  internal 
oblique,  preferably  where  it  is  becoming  aponeurotic,  and  are  tied  on  the  external 
surface  of  the  latter  (Fig.  803). 

"The  internal   oblique   muscle,   mobilized,  and   possibly  further  released  by 


TREATMENT   OF   HERNIA. 


705 


Fig.  803. — Halsted's  Operation. 
Suture  of   the  cremaster  to  the  internal  oblique. 


^^^P^M'^/l.^.mr' 


Fig.   804. — Halsted's  Operation. 
Suture  of  the  lower  edge  of  the  internal  obhque  to  Poupart's  ligament. 
VOL.  II — 45 


706 


OPERATIONS   FOR   INGUINAL    HERNIA. 


incising  the  anterior  sheath  of  the  rectus  muscle,  is  stitched  (the  conjoined  tendon 
also)  to  Poupart's  ligament  in  the  Bassini-Halsted  manner  (Fig.  804).  Catgut  is 
usually  employed  for  this  suture. 


Fig.  805. — Halsted's  Operation. 
Suture  of  the  aponeurosis  of  the  external  oblique. 


"The  aponeurosis  of  the  external  oblique  muscle  is  overlapped  (Fig.  805).     This: 
is  known  as  Andrews'  method,  although  devised  independently  by  us. 


Fig.  806. — Hai>ti;i/s   Operation. 
Suture  of  the  margin  of  aponeurosis  to  Poupart's  ligament. 

"The  skin  is  closed  with  a  buried  continuous  silver  suture,  and  the  incision 
covered  with  five  or  six  layers  of  silver  foil.     It  is  unnecessary  to  dress  or  examine  a 


TREATMENT   OF   HERNIA. 


707 


Aponeurcbis   of 

ext.  obliaue 


>>f-Br 


-•at. 


Fig.  807. — Halsted's  Operation. 
Sectional  view. 


wound  closed  in  this  manner  for  two  weeks,  when  the  wire  may  be  withdrawn. 
Patients  are  kept  in  bed  from  eighteen  to  twenty-one  days." 

Bloodgood,  whose  wide  chnical  experience  and  painstaking  study  of  the  after- 
histories  of  cases  of  inguinal  hernia 
treated  by  the  radical  operation  entitle 
his  opinion  to  general  acceptance,  thus 
describes  his  technic,  in  a  personal  com- 
munication : 

"At  the  present  time  the  operation  is 
performed  as  follows:  After  dividing 
the  aponeurosis  of  the  external  oblique 
muscle  the  internal  oblique  is  separated 
well  up  to  the  rectus  sheath  as  a 
McBurney  gridiron.  The  sac  is  excised 
and  closed.  In  doing  this  all  the  cover- 
ings of  the  sac  with  the  cremaster  muscle  are  preserved.  In  closing  the  wound  the 
loosened  internal  oblique  muscle  and  the  conjoined  tendon  down  to  the  cord  are 
sutured  to  Poupart's  ligament  at  some  distance  from  the  line  of  division,  then  this 

edge  of  Poupart's  ligament 
is  sutured  to  the  sheath  of 
the  rectus,  to  the  fascia  of 
the  linea  semilunaris,  and 
to  the  muscle  of  the  in- 
ternal oblique.  This,  I 
think,  is  the  chief  point  of 
the  operation,  the  fixation 
of  the  widely  separated  in- 
ternal oblique  muscle  to 
Poupart's  ligament.  The 
aponeurosis  of  the  exter- 
nal oblique  is  sutured  over 
the  structures  just  men- 
tioned which  have  been 
approximated.  If  the 
veins  are  large,  they  are 
excised  as  in  varicocele. 
This  is  the  method  that  I 
have  employed  since  my 
study  of  hernia  was  com- 
plete. I  have  found  it 
necessary  to  transplant  the 
rectus  muscle  in  a  few  cases,  and  as  far  as  I  know  I  have  had  but  one  recurrence.'* 
The  patient  is  kept  in  bed  for  ten  days. 


I"iG.  808. — Bassixi's  Operation,  I. 

Grooved  director  in   inguinal  canal,  lifting  up   aponeurosis  of  external 

oblique. 


708 


OPERATIONS    FOR   INGUINAL    HERNIA. 


Ferguson/  the  simplicity  of  whose  procedure  commends  it,  but  not  more  than 
the  success  which  has  attended  its  appHcation,  notes  that  the  important  feature  in 


!^_S  ec/<eT\ 


Fig.  809. — Bassim's   Upehation,  II. 
Sac  and  cord  raised  en  masse  and  held  with  fold  of  gauze. 


3c-c-ker,\ 


Fig.  810. — Bassini's  Operation,  III 
Sac  dissected  from  cord,  opened,  examined,  and  neck  ligatured. 

the  radical  cure  of  obhque  inguinal  hernia  is  the  proper  suturing  of  the  internal 

oblique  muscle  to  its  tendon  and  the  inner  aspect  of  Poupart's  ligament  as  low 

^  Ferguson:  "The  Technique  of  Modern  Operations  for  Hernia,"  Chicago,  1907. 


TREATMENT    OF    HERNIA. 


709 


down  as  possible  without  undue  tension,  after  having  ablated  the  sac  and  strength- 
ened the  internal  ring  with  a  few  stitches  above  the  root  of  the  cord. 


Fig.   811. — Bassixi's  Operation,  IV. 
Sac  removed,  cord  drawn   aside,  and  stitching  of  lower    fibers  of   internal  oblique  and   transversalis  muscle  to 

Poupart's  ligament  from  within  outward. 


Fig.  812. — Bassini's  Operation,  V. 
Arched  muscular  fibers  and  conjoined  tendon  sewed  to  Poupart's  ligament. 

He  makes  a  curved  incision  beginning  half  an  inch  below  the  anterior  superior 
process  of  the  ilium,  ending  near  the  pubic  bone.     The  superficial  fascia  is  divided 


'10 


OPERATIONS    FOR    INGUINAL    HERNIA. 


with  as  little  bleeding  as  possible,  the  vessels  being  caught  as  they  are  exposed  and 
cut  between  hemostats.  The  aponeurosis  of  the  external  oblique  is  freed  and  the 
cut  is  carried  through  the  external  abdominal  ring  and  the  intercolumnar  fascia, 
with  separation  of  the  longitudinal  fibers  of  the  external  aponeurosis,  beyond  the 
internal  ring.  The  sac  is  opened  at  its  neck,  freed  of  contents,  dissected  from  the 
cord  and  internal  ring,  and  either  ligated  or  sutured  high  up.  The  cord  is  not 
disturbed,  though  in  varicocele  complicated  with  hernia  this  would  be  dealt  with  in 
accordance  with  surgical  principles. 

The  cremaster  muscle,  which  is  allowed  to  hug  the  cord,  is  reattached  to  the 
internal  oblique  muscle.  Fat  aggregations  should  be  removed.  The  internal  oblique 
and  transversalis  muscles  are  sutured  to  the  internal  aspect  of  Poupart's  Hga- 
ment,  the  slack  of  the  transversalis  fascia  and  cremaster  muscle  being  taken  up  at 

the  same  time.  The  suturing 
is  extended  fully  two-thirds 
down  along  Poupart's  ligament, 
care  being  taken  to  avoid  split- 
ting the  latter  by  grasping  the 
same  longitudinal  fibers  in  the 
separate  stitches.  The  con- 
joined tendon  being  deficient  or 
absent  in  the  case  of  direct 
inguinal  hernia,  the  sheath  of 
the  rectus  muscle  is  freely 
opened  to  the  pubic  bone  and 
the  muscle  brought  across  the 
weak  part  to  Poupart's  liga- 
ment. The  aponeurosis  of  the 
external  oblique  muscle  is  closed 
by  overlapping. 

The  patient  is  kept  in  bed 
for  three  weeks  and  a  pad  and 
bandage,  but  no  truss,  are  worn  for  three  months  thereafter. 

For  ligatures  and  sutures  Ferguson  uses  Nos.  00,  0,  and  1  of  chromic  catgut 
throughout  the  operation;  No.  1  to  tie  off  the  sac,  the  other  sizes  for  the  coaptation 
of  the  remaining  structures.  He  states  that  there  has  been  no  return  in  2500 
patients  operated  on  by  different  surgeons. 

Bassini's  operation  has  for  its  principle  the  ligation  and  removal  of  the  sac, 
the  complete  freeing  of  the  cord  from  its  bed,  and  the  suturing  of  the  lower  border 
of  the  internal  oblique  muscle  and  the  conjoined  tendon  to  the  inner  aspect  of 
Poupart's  ligament  beneath  the  cord.  The  latter  is  then  dropped  back,  the  external 
oblique  muscle  is  closed  over  it,  leaving  at  the  position  of  the  external  ring  just 
enough  room  for  the  passage  of  the  cord  without  constriction  of  its  blood-vessels. 
From  2  to  5  per  cent,  of  recurrences  are  reported  after  the  operation,  mostly  in 
oblique  hernias,  at  the  outer  angle  of  the  wound.     (See  Figs.  808,  813.) 


Fig.  813. — Bassini's  Operation,  VI. 
Aponeurosis  of  external  oblique  sewed  together. 


TREATMENT    OF   HERNIA.  711 

It  will  be  noted  that  the  operations  described  by  Bloodgood  and  Halsted  and 
Ferguson  are  in  many  respects  alike.  All  leave  the  cord  undisturbed.  All  advocate 
free  dissection  of  the  internal  oblique  muscle  and  all  provide  a  firm  musculofascial 
wall  in  the  inguinal  region.  Their  methods  are  simple,  easily  applicable,  and  are 
free  from  the  danger  of  either  thrombosis  of  the  pampiniform  plexus  or  atrophy  of 
the  testis.  Moreover,  the  published  results  as  to  ultimate  cure  are  as  good  as  those 
following  the  Bassini  operation,  if  not  better,  and  these  methods  have  been  adopted 
by  men  who  have  given  the  Bassini  method  an  exhaustive  trial. 

Surgical  cleanliness  is  the  first  essential  to  any  form  of  radical  cure.  Bloodgood 
was  the  first  to  show  the  important  part  played  by  rubber  gloves  in  the  attainment 
of  this  end  in  the  treatment  of  hernia.  For  the  direct  inguinal  hernias  of  elderly 
people  appearing  as  a  general  prolapse  with  atrophic  muscles  and  weak  fascia,  the 
class  of  cases  in  which  the  operation  for  radical  cure  are  least  promising,  Bartlett's^ 
successful  experience  with  his  silver  filigree  in  ninety-eight  cases  of  abdominal 
hernia,  some  of  them  suppurating,  gives  promise  of  a  method  simple  in  application 
and  likely  to  be  extremely  efficacious.  Nor  with  the  silver  wire  network  implanted 
deeply,  in  contact  with  the  peritoneum,  does  there  seem  to  be  any  tendency  for  the 
foreign  substance  to  cause  either  immediate  or  remote  suppuration. 

The  proper  choice  of  a  ligature  material  is  of  scarcely  less  importance.  Catgut 
which  will  not  be  absorbed  for  at  least  two  weeks  is  the  ideal  material.  It  is  open 
to  the  objection  that  in  large  sizes  it  is  impossible  to  be  assured  of  its  sterility. 
The  small  sizes  are  absorbed  too  rapidly.  Therefore  tendon  would  seem  to  be  the 
best  material  to  use  for  buried  sutures,  since  both  silk  and  silver  wire  remain  indef- 
initely as  foreign  bodies  and  may  prove  foci  of  suppuration  months  after  operation. 

The  apposition  of  structures  designed  to  form  a  new  abdominal  wall  must  be 
accomplished  without  tension.  This  is  best  furthered  by  free  dissection.  The 
apposition  must  be  accurate. 

The  avoidance  of  intra-abdominal  tension,  particularly  when  this  is  associated 
with  the  erect  position,  is  desirable  for  a  period  of  at  least  two  weeks  after  operation. 
For  six  weeks  more  the  area  of  operation  should  receive  support  by  a  broad  compress 
and  a  spica  bandage,  preferably  of  elastic  webbing.  A  truss  may  be  worn  provided 
it  be  furnished  with  a  broad  flat  plate  and  makes  appreciable  pressure  when  there 
is  increase  of  intra-abdominal  tension. 

^  Bartlett,  Willard:  Personal  communication,  and  "  Five  Years'  Experience  with  an  Original 
Filigree  Intended  to  Prevent  and  to  Cure  Abdominal  Hernise,"  Jour.  Am.  Med.  Assoc,  Sept.  8, 
1906,  pp.  754-760. 


CHAPTER  XLII. 

THE  USE  OF  DRAINAGE  IN  ABDOMINAL  AND  PELVIC  SURGERY, 
By  Brooke  M.  Anspach,  M.D. 

History. — The  first  real  adaptation  of  the  principles  of  drainage  to  abdominal 
surgery  was  made  by  Peaslee/  in  1871.  Previous  to  that  time  drainage  had  been 
unintentionally  provided  in  the  operations  of  ovariotomy  and  of  hysteromyomectomy. 
In  the  first  it  was  customary  to  secure  the  pedicle  by  means  of  a  clamp  which  was 
left  projecting  from  the  wound.  In  the  second  there  was  so  much  dread  of  hemor- 
rhage or  infection  that  the  sutures  securing  the  cervix  were  brought  out  through  the 
incision,  or  the  cervix  itself  was  fastened  in  the  lower  part  of  the  abdominal  wound. 

Peaslee,  however,  was  the  surgeon  who  considered  it  desirable  to  drain  the  pelvis, 
and  who  first  took  measures  to  that  end.  Peaslee  feared  the  "red  serous  fluid" 
which  he  had  found  in  the  pelvis  after  death  from  ovariotomy,  and  to  his  mind 
the  stagnation,  decomposition,  and  absorption  of  it  was  the  source  of  the  fatal 
septicemia  which  so  often  followed  operation.  This  fluid  was  the  result  of  ooz- 
ing from  the  adhesions  which  had  been  broken  during  the  enucleation  of  the 
tumor,  or  it  represented  cyst  contents  spilled  in  the  pelvis,  ascitic  fluid  left  there 
or  secreted  after  operation,  or  purulent  material  from  granulating  surfaces.  In 
order  to  prevent  accumulations  in  the  peritoneal  cavity,  Peaslee  irrigated  the  pelvis 
by  means  of  a  catheter  introduced  through  a  posterior  vaginal  or  a  suprapubic  in- 
cision, using  for  this  purpose  a  reservoir  bag  of  a  capacity  of  three  quarts,  and  irrigat- 
ing until  the  fluid  returned  clear.     In  one  case  nine  quarts  were  necessary. 

The  ideas  of  Peaslee  were  widely  adopted,  notably  by  Sims,^  who  soon  proposed 
the  routine  use  of  drainage.  While  Peaslee  had  advised  it  for  cases  in  which  septi- 
cemia was  especially  feared,  Sims  advocated  it  as  a  routine  measure,  pointing  out 
the  fact  that  the  natural  drainage  point  for  pelvic  operations  was  through  Douglas' 
pouch. 

It  was  not  until  Schroder,^  in  1875,  drew  attention  to  the  role  played  by  infec- 
tion that  any  argument  over  the  question  of  drainage  occurred.  Schroder  announced 
that  the  "serous  red  exudate"  was4iarmless,  provided  no  infection  had  been  intro- 
duced into  the  peritoneal  cavity  during  the  operation.  He  reported  several  cases  in 
which  the  exudate  had  occurred  followed  by  recovery. 

Nevertheless  the  principles  of  drainage  prevailed,  and  many  devices  were  invented 

^Peaslee,  E.  R.:  "Injections  into  the  Peritoneal  Cavity  after  Ovariotomy,"  Amer.  Jour. 
Obst.,  1871,  iii,  p.  300. 

^  Sims,  J.  Marion:  "On  Ovariotomy,"  N.  Y.  Med.  Jour.,  1872,  vi,  Dec.  16,  p.  561. 
^  Schroder,  Karl:   "Ueber  die  Drainage  des  Douglaschen  Raumesbei  der  Ovariotomie,"  1875. 

712 


ANATOMY   AND    PHYSIOLOGY    OF    PERITONEUM.  713 

to  make  it  effectual.  Koberle's  glass  tube,  Sanger's  glass  tube  and  wick,  and  the 
Mikulicz  gauze  bag  are  evidences  of  the  efforts  in  this  direction. 

Later  on  the  truth  of  Schroder's  assertion  was  appreciated  by  such  men  as 
Zweifel,  Olshausen,  and  Czempkin,  who  objected  to  all  forms  of  drainage.  Ols- 
hausen^  reported  that  as  early  as  the  year  1882  he  had  abandoned  drainage  in  ovari- 
otomy cases,  and  that  about  this  time  Kocher  (quoted  by  Olshausen)  followed  the 
same  plan. 

The  earliest  and  the  most  important  work  in  this  country  was  that  of  Clark,^ 
who  reviewed  one  thousand  seven  hundred  cases  of  abdominal  section  observed 
in  Kelly's  clinic  at  Baltimore.  This  author  proved  beyond  question  the  uselessness 
of  drainage  in  most  celiotomies  for  pelvic  disease,  and  pointed  out  the  dangers  inci- 
dent to  its  employment.  He  reviewed  the  histologic  and  experimental  studies  of 
Muscatello,  Wegner,  Grawitz,  Pawlowsky,  Waterhouse,  Cobbett  and  Melsome, 
and  others,  and  introduced  a  technic  which  practically  applied  what  was  at  that 
time  known  concerning  the  function  of  the  peritoneum.  Following  his  work,  the 
limitations  of  drainage  were  more  generally  recognized,  and  the  types  of  cases  in 
which  it  was  considered  good  practice  steadily  diminished. 

The  last  noteworthy  occurrence  in  the  history  of  drainage  was  the  introduction  by 
Fowler^  of  a  postural  method  almost  exactly  opposite  to  the  plan  proposed  by  Clark. 

Anatomy  and  Physiology  of  Peritoneum,  with  Especial  Reference  to 
Peritoneal  Absorption  and  Localization. — It  has  been  shown  by  Muscatello, 
Waterhouse,  and  others,  that  the  chief  area  of  lymphatic  absorption  from  the  peri- 
toneal cavity  is  in  its  upper  part — through  the  peritoneum  covering  the  diaphragm 
and  especially  about  its  root.  Absorption  occurs  here  much  more  rapidly  than 
elsewhere,  and  is  aided  by  elevation  of  the  pelvis.  The  absorptive  power  of  the 
peritoneum  is  enormous,  according  to  Wegner,  being  3  to  8  per  cent,  of  the  entire 
body-weight  in  an  hour. 

Minute  foreign  bodies  left  in  the  peritoneal  cavity  are  carried  up  through  the 
diaphragm  into  the  lymphatic  duct,  thence  to  the  blood  and  the  visceral  organs. 
The  minute  foreign  particles  are  largely  conveyed  by  leukocytes  which  have  encap- 
sulated or  surrounded  them.  The  greater  the  amoimt  of  fluid  in  which  the  foreign 
particles  are  suspended,  the  more  rapidly  does  absorption  occur.  When  a  foreign 
body  is  of  such  a  size  that  its  deportation  or  absorption  is  impossible,  it  becomes  an 
irritant  to  the  peritoneum  and  is  encapsulated  by  an  exudation  of  fibrin,  which 
glues  the  intestines  or  the  omentum  or  both  about  it,  and  isolates  the  foreign  body 
from  the  general  cavity  of  the  peritoneum.  The  absorptive  power  from  other  parts 
of  the  general  peritoneal  cavity  is  much  less  than  from  the  diaphragmatic  area,  and 
upon  this  fact  both  the  postural  methods  of  treatment,  namely,  that  of  Clark  and 
that  of  Fowler,  depend. 

1  Olshausen,  R.:   "Die  Krankheiten  der  Ovarien,"  1886,  Stuttgart,  S.  311. 

^  Clark,  J.  G.:  "A  Critical  Review  of  Seventeen  Hundred  Cases  of  Abdominal  Section  from  the 
Standpoint  of  Intraperitoneal  Drainage,"  Amer.  Jour.  Obstet.,  1897,  xxxv.  No.  4. 

^  Fowler,  G.  R.:  "The  Toilet  of  the  Peritoneum  in  Appendicitis,"  Trans.  Amer.  Surg.  Assoc, 
1903,  xxi,  p.  23. 


714 


DRAINAGE   IN   ABDOMINAL   AND    PELVIC    SURGERY. 


Purpose  of  Drainage. — Peaslee's  original  purpose  in  using  peritoneal  drainage 
was  to  prevent  the  accumulation  of  toxic  fluids.  It  appears  at 
first  sight  that  this  would  be  easy  enough  to  secure  by  provid- 
ing an  exit  from  the  most  dependent  part  of  the  abdominal 
cavity  and  by  placing  the  patient  in  such  a  position  that  perito- 
neal collections  would  gravitate  in  that  direction.  As  a  matter 
of  fact,  however,  any  drain  so  far  adopted  for  the  purpose  is 
quickly  walled  off  from  the  general  cavity  of  the  peritoneum, 
and  after  a  few  hours  drains  only  that  part  which  lies  immedi- 
ately in  its  vicinity.  This  has  been  shown  repeatedly  both  by 
clinical  and  by  experimental  investigations.  The  amount  of 
discharge  from  the  drain  is  usually  directly  in  proportion  to  its 
bulk,  and  is  largely  a  transudate  from  the  serous  surfaces  with 
which  it  comes  in  contact.  Nevertheless,  a  properly  made  and 
correctly  placed  drain  may  be  of  great  service  for  a  limited  time, 
serving  to  remove  infectious  products  and  to  direct  the  flow  of 
toxic  fluids  externally  and  prevent  their  absorption  by  the  peri- 
toneum. But,  after  four  to  six  hours,  the  products  that  are  re- 
moved by  a  drain  are  limited  of  necessity  to  those  escaping  from 
the  areas  immediately  in  contact  with  the  drainage  material. 
Thus  the  office  of  a  drain  changes  at  the  end  of  about  six  hours, 
and  it  afterward  serves  merely  to  encourage  the  formation  of 
peritoneal  adhesions  or  exudates  which  shut  off  the  originally 
drained  area  from  the  abdominal  cavity.  If  the  drainage  mate- 
rial has  been  properly  placed,  and  if  it  is  allowed  to  remain  for 
a  certain  time,  these  adhesions  will  safely  exclude  the  infected 
area. 

Distinction  between  Drainage  and  Packing. — This  leads 
to  a  distinction  between  a  drain  and  a  protective  pack.  Drain- 
age may  be  maintained  for  some  time  from  an  encapsulated 
abscess  or  from  a  hollow  viscus  like  the  gall-bladder.  Any 
other  drain  after  six  hours  becomes  a  protective  pack.  A 
drain  in  the  peritoneal  cavity  will  be  efficient  for  a  short  period 
of  time,  but  after  four  to  six  hours  it  becomes  walled  off  from 
the  surrounding  parts,  and  thereafter  simply  excites  the  forma- 
tion of  more  encapsulating  adhesions  or  exudates.  It  is  then 
in  a  sense  no  longer  a  drain,  but  a  device  which  effectually 
isolates  the  area  it  occupies  from  the  general  peritoneal  cavity. 
In  many  instances  this  accomplishes  the  desired  end  and  pre- 
vents the  spread  of  an  infection. 

Materials   Used   for  Drainage  and  General   Consider- 
ations.— The  efficiency  of  a  drain  during  the  first  few  hours 
depends  on  the  anatomic  configuration  of  the  parts,  the  position  in  which  the 


Fig.  814. — Cigarette 
Drain    made    by 
Rolling  a  Piece 
OF     Rubber-dam 
AROUND    A   Strip 
or  Gauze. 
If  prepared  before 
operation,    rubber    ce- 
ment  will    be  needed. 
If   made  at  the  time, 
a    little    moisture    will 
cause  the  rubber-dam 
to   adhere   and   no   ce- 
ment will  be  necessary. 
In  all  cigarette  drains 
it  is  important  to  see 
that    the    gauze   inlay 
does     not    block     the 
rubber  sheath. 


MATERIALS    USED    AND    GENERAL    CONSIDERATIONS. 


715 


patient  is  placed,  the  character  of  the  Uc|uid  to  be  drained,  and  the  material  used 
for  this  purpose.  An  ideal  drain,  therefore,  should  be  conducive  to  rapid  absorp- 
tion and  a  minimum  of  reaction  along  the  drainage  tract.  A  combination  of  gauze 
and  rubber  is  the  best.  This  may  be  either  in  the  form  of  the  cigarette  drain,  as  used 
by  Morris  (Fig.  814),  or  it  may  be  a  rubber 
drainage-tube  of  large  caliber  divided  spir- 
ally throughout  its  length  (Fig.  815)  and 
containing  a  loose  inlay  of  gauze.  After 
twenty-four  to  forty-eight  hours,  the  gauze 
v^ick  may  be  drawn  out,  leaving  the  rubber 
tube,  through  which,  in  a  few  selected  cases, 
as,  for  example,  an  abscess  cavity  well  walled 
off,  gentle  irrigation  may  be  practised.  One 
of  the  best  drains  can  be  made  from  a  con- 
dom stuffed  lightly  with  gauze  and  cut  open 
at  the  end.  Fenestrated  glass  or  rubber 
tubes  are  objectionable  because  the  fenestra 
quickly  become  blocked  by  the  surrounding 
viscera — bowel,  omentum,  etc.  Glass  drain- 
age-tubes should  not  be  used  except  for  a 
very  brief  period  of  time,  otherwise  they 
may  cause  pressure  necrosis  of  the  intestine 
with  consequent  hemorrhage  or  fecal  fistula. 
When  drainage  is  indicated  after  the  closure 
of  a  hollow  viscus,  as  intestinal  anastomosis, 
cholecystenterostomy,  etc.,  care  should  be 
taken  that  the  drainage  material  causes  no 
pressure  on  the  line  of  sutures,  the  drains 
being  placed  in  the  immediate  neighbor- 
hood, but  not  in  close  contact. 

Drainage  by  capillary  attraction  alone  is 
not  very  effectual  unless  the  fluid  to  be 
drained  is  thin.  Thus,  Yates^  in  his  exper- 
iments found  that  serum  was  absorbed  rap- 
idly, a  slightly  albuminous  exudate  slowly, 
and  pus  almost  not  at  all.  Capillary  drain- 
age will  be  much  more  effectual,  however, 
if,  as  pointed  out  by  Coffey,^  the  external 
opening  is  large.     Constriction  of  the  drainage  material  at  the  external  wound  is 


Fig.  815. — Cigarette 
Drain  made  by 
Cutting  a  Rub- 
ber Tube  Spiral- 
ly AND  Inlaying 
a  Piece  of  Gauze. 
This  form  is  per- 
haps the  most  efficient 
of  any  cigarette  drain. 


Fig.  816. — Cigarette 
Dr.\in  made  by 
Cutting  a  Piece 
OF  Rubber  Tub- 
ing Longitud- 
inally AND  In- 
laying A  Strip 
OF  Gauze. 


1  Yates,  John  L.:    "An  Experimental  Study  of  the  Local  Effects  of  Peritoneal  Drainage," 
Surg.  Gynec.  and  Obst.,  1905,  vol.  i,  No.  6,  p.  473. 

^  Coffey,  R.  C:    "The  Principles  and  Mechanics  of  Abdominal  Drainage,"  Jour.  Amer.  Med. 
Assoc,  1907,  vol.  xlviii,  No.  11,  p.  937. 


716 


DRAINAGE   IN   ABDOMINAL   AND    PELVIC    SURGERY. 


not  conducive  to  effectiveness.  The  exit  of  the  drain  should  be  covered  with 
many  layers  of  gauze,  so  as  to  increase  as  far  as  possible  the  capillary  attraction, 
and  an  effort  should  be  made,  either  by  introducing  the  drain  at  the  lowest  point 
of  the  infected  area,  or  by  placing  the  patient  in  a  certain  position,  or  by  both,  to 
add  the  force  of  gravity. 

The  extent  to  which  drainage  can  be  used  safely  is  limited  by  the  danger  associ- 
ated with  the  local  reaction  it  produces.  Thus,  drainage  of  a  large  area  may  result 
in  numerous  adhesions  and  lead  to  intestinal  strangulation,  or  the  patient  may  suffer 
subsequently  with  severe  pain  or  with  nausea  and  gastric  disturbance.  Drainage  is 
associated  with  other  risks,  being  sometimes  the  portal  of  an  infection.     Robb  and 


1  2 

Fig.  817. — Showing  the  Method  of  Making  Gauze   Drainage  Strips. 
A  piece  of  gauze  is  talcen  3  yards  in  length  and  four  times   the  width  of  the  desired  strip  and  folded  as 
indicated.     The  two  selvage  ends  are  first  folded  toward  the  middle  line  of  the  strip. .    Another  fold  is  now  made 
along  the  median  line  (2),  producing  the  effect  shown  in  3.     By  this  method  the  selvage  edges  are  turned  in. 

Ghriskey^  found  that  notwithstanding  the  most  painstaking  efforts  to  exclude  infec- 
tion drains  became  the  seat  of  septic  organisms  in  44  per  cent,  of  cases.  A  drain 
also  usually  prolongs  convalescence,  gives  a  certain  amount  of  discomfort,  and  pre- 
disposes to  suppuration  of  the  incision,  fecal  fistula,  and  ventral  hernia. 

When  is  Drainage  Required? — It  is  evident  from  what  has  been  said  that  there 
are  reasons  for  avoiding  drainage  whenever  possible.  It  has  been  shown  by  Water- 
house  and  others  that  the  peritoneum  is  able  to  take  care  of  a  certain  amount  of 

'  Robb,  Hunter,  and  Ghriskey,  A.  A.:  "Infection  through  the  Drainage  Tube;  the  Result 
of  the  Bacteriological  Examination  of  Drainage  Tube  Fluids  in  Sixteen  Consecutive  Cases  of 
Celiotomy,"  Johns  Hopkins  Hosp.  Bull.,  July,  1891,  p.  93. 


WHEN   IS   DRAINAGE    REQUIRED?  717 

infection,  and  that  the  sooner  bacteria  and  fluids  left  in  the  abdominal  cavity  after 
operation  are  absorbed,  the  less  likely  is  peritonitis  to  occur.  Experimental  and 
clinical  evidence  of  this  kind  led  Clark  and  others  to  abandon  drainage,  with  its 
many  disadvantages,  and  rely  on  the  absorptive  powers  of  the  peritoneum  to  rid 
itself  of  infection. 

Clark  and  Norris  in  addition  proved  by  their  experiments  that  a  diluted  infection 
was  handled  with  more  rapidity  than  an  undiluted  one,  and  made  a  practice  after 
laparotomy  of  leaving  a  liter  of  salt  solution  in  the  abdominal  cavity.  This  served 
the  double  purpose  of  diluting  the  infection  and  of  increasing  the  urinary  excretion. 

In  order  to  increase  absorption  through  the  diaphragm,  Clark  inaugurated  the 
plan  of  raising  the  foot  of  the  bed  so  as  to  assist  the  natural  direction  of  the  perito- 
neal currents  by  tlie  force  of  gravity.  His  plan  of  favoring  rapid  absorption  by  throw- 
ing the  peritoneal  fluid  toward  the  diaphragm  has  been  opposed  by  many  with  the 
objection  that  in  this  way  an  infection  which  might  be  kept  localized  is  made  general. 
Likewise,  Fowler,  Coffey,  and  others  doubt  the  wisdom  of  emptying  into  the  general 
circulation  a  great  quantity  of  toxic  substances,  and  question  the  ability  of  the  re- 
sistant forces  of  the  body  to  successfully  cope  with  them.  Exemplifying  this  doubt 
Fowler  advocates  a  sitting  posture  in  order  to  keep  infectious  products  in  the  least 
absorbing  part  of  the  peritoneal  cavity  until  they  can  be  encapsulated  or  removed. 

Careful  consideration  shows  that  of  necessity  there  must  be  a  difference  between 
the  views  of  the  gynecologist  and  the  abdominal  surgeon.  A  majority  of  purulent 
collections  in  the  pelvis  are  due  to  the  gonococcus,  an  organism  which  is  little  dis- 
posed to  attack  the  general  peritoneum.  Non-puerperal  pelvic  infections  so  com- 
monly become  walled  off  from  the  general  peritoneum  that  operation  is  delayed 
until  the  acuteness  of  the  infection  has  subsided.  At  the  time  of  operation  the 
pus  is  feebly  infectious  or  even  sterile,  soiling  of  the  operative  field  is  of  little  moment, 
and  a  careful  cleansing  is  all  that  is  required. 

When  the  pelvic  infection  dates  from  abortion,  labor,  or  operative  manipulation, 
it  less  often  becomes  innocuous,  and  the  danger  of  peritonitis  from  intra-abdominal 
manipulation  is  greatly  increased.  Therefore  the  vaginal  route  for  operation, 
drainage  through  the  vagina,  and  Fowler's  position  become  advisable  in  order  to 
lessen  the  risk  of  infecting  the  general  peritoneum. 

Acute  infections  of  the  appendix,  the  gall-bladder,  the  stomach,  and  the  pan- 
creas are  again  virulent  in  type  and  less  likely  to  localize,  so  that  drainage  will  be 
required  oftener  than  after  operation  for  old  inflammatory  lesions  of  the  pelvis. 

In  appendicitis  complicated  by  purulent  collections,  for  example,  it  is  difficult 
to  know  when  to  omit  drainage.  Westbrook^  has  said:  "While  it  is  true  that  the 
peritoneum  may  be  relied  upon  to  take  care  of  a  certain  quantity  of  infectious  material, 
we  do  not  know  in  any  individual  case  what  that  quantity  may  be.  An  estimate 
of  the  individual's  comparative  resistance  is  possible,  but  there  is  no  means  of 

^  Clark,  J.  G.,  and  Norris,  C.  C:  "Peritoneal  Saline  Infusions  in  Abdominal  Operations," 
Jour.  Amer.  Med.  Assoc,  Jan.  30,  1904,  p.  281. 

^  Westbrook,  R.  W.:  "The  Question  of  Drainage  in  Appendicitis  with  Outlying  Appendical 
Infection,"  Brooklyn  Med.  Jour.,  Feb.,  1902,  xvi,  88. 


718  DRAINAGE   IN   ABDOMINAL    AND    PELVIC    SURGERY. 

exactly  determining  at  the  time  of  the  operation  the  amount  and  the  virulence  of  the 
infection.  If  the  surgeon  decides  to  omit  drainage  in  a  case  of  appendicitis  with 
outlying  infection,  he  must  do  so  relying  entirely  upon  his  personal  ability  to  gage  the 
clinical  facts  in  the  case  and  the  nature  and  the  extent  of  the  pathologic  process 
exposed  at  operation. " 

While  it  is  difficult,  and  often  impossible,  in  abdominal  or  pelvic  inflammation 
to  correctly  estimate  the  severity  of  the  infection,  it  should  always  be  the  surgeon's 
desire  to  note  every  clinical  fact  in  the  case  which  tends  to  throw  any  light  upon 
this  question.  Certainly,  clinical  evidence  has  shown  that  pelvic  infections  fol- 
lowino-  abortion,  labor,  or  instrumental  manipulation  of  the  uterus  are  more  vio- 
lent than  other  pelvic  infections,  and,  consequently,  should  be  drained  much  oftener, 
and  even,  it  might  be  said,  as  a  rule.  In  cases  of  inflammation  of  the  appendix,  the 
gall-bladder,  and  the  pancreas,  with  an  outlying  peritoneal  involvement,  it  is  safer 
to  use  a  limited  amount  of  drainage  in  the  majority  of  cases,  and  by  this  means 
assist  the  peritoneum  in  disposing  of  the  infectious  material. 

General  Technic  of  Intraperitoneal  Operations  in  Cases  of  Infection. — 
In  operating  on  any  intraperitoneal  organ  where  an  infected  area  or  collection  is 
known  to  exist  or  is  suspected,  the  surrounding  intestines  should  be  pushed  to  one 
side  and  an  abundant  gauze  barrier  placed  between  the  diseased  organ  and  the 
general  peritoneal  cavity.  After  the  offending  part  has  been  removed,  the  perito- 
neal surface  in  its  immediate  neighborhood  should  be  cleaned  by  sponges  wrung 
out  of  salt  solution.  If  drainage  is  indicated,  the  drains  are  placed  in  position 
before  the  protective  layer  of  gauze  shutting  off  the  general  peritoneum  is  taken  out. 


DRAINAGE  OF  PARTICULAR  ORGANS  OR  PARTS. 

Uterus. — Drainage  of  the  uterus  may  be  required  after  operation  for  septic 
endometritis  and  metritis  following  labor  or  abortion,  retained  and  decomposing 
products  of  conception,  sloughing  intrauterine  growths,  pyometra,  hematometra,. 
etc.  The  cervix  must  be  thoroughly  dilated.  The  end  of  a  gauze  strip  is  carried 
to  the  top  of  the  endometrial  cavity  and  the  uterus  is  lightly  filled  with  gauze, 
especial  care  being  taken  that  there  is  no  blocking  of  the  cervical  canal. 

Pelvic  Peritoneum  and  Uterine  Adnexa. — Drainage  is  not  required  after 
most  celiotomy  operations  for  non-puerperal  pelvic  inflammatory  disease,  the  pus 
often  being  sterile  or  weakly  infectious  at  the  time  the  operation  is  performed. 
In  addition,  the  intestines  and  the  abdominal  cavity  can  be  walled  ofi^  with  gauze, 
and  any  pus  which  escapes  during"  the  operation  can  be  sponged  away  without 
endangering  the  general  peritoneum.  After  completing  the  intrapelvic  procedure, 
the  pelvis  should  be  painstakingly  cleaned,  before  the  protective  barrier  of  gauze  is 
removed  and  the  intestines  and  the  omentum  are  allowed  to  fall  into  the  pelvis. 

That  the  infrequent  use  of  drainage  after  celiotomy  for  pelvic  disease  is  justified 
is  indicated  by  the  work  of  Olshausen,^  who  employs  drainage  in  very  exceptional 

1  Olshausen,  R.:  "Wider  die  Drainage,"  Zeit.  f.  Geburtsh.  u.  Gynak.,  1903,  Bd.  xlviii,  S.  305.. 


DRAINAGE  OF  PARTICULAR  ORGANS  OR  PARTS.  719 

instances  only.     The  propriety  of  drainage,  he  thinks,  would  be  questioned  espe- 
cially in  four  classes  of  cases: 

1.  When  pus  or  necrotic  material  has  been  spilled  during  the  operation  into  the 
peritoneal  cavity. 

2.  When  a  malignant  tumor  cannot  be  fully  extirpated,  or  when  an  infiltrated 
abscess  wall  is  left  behind. 

3.  Penetrating  wounds  of  the  intestine  or  the  bladder. 

4.  Operations  which  may  be  characterized  as  unclean,  in  which  a  large  quantity 
of  fluid  must  remain  in  the  peritoneal  cavity.  Examples  of  this  are  found  in  large 
ovarian  tumors  when  some  of  the  contents  is  spilled  into  the  peritoneal  cavity;  in 
pseudo-myxoma  peritonei;    and  in  old  hematoceles. 

In  all  these  cases  Olshausen  makes  as  careful  a  toilet  of  the  peritoneal  cavity 
and  pelvis  as  possible  and  then  closes  the  incision  without  drainage.  In  one 
thousand  five  hundred  fifty-five  celiotomies  performed  by  him  in  six  years,  there 
were  one  hundred  fourteen  in  which  he  considered  the  advisability  of  drainage, 
but  did  not  use  it.  Sixty-five  of  these  belonged  to  the  first  class  and  resulted  in 
fourteen  deaths;  ten  belonged  to  the  second  class — one  death;  twenty  belonged 
to  the  third  class — seven  deaths ;  eighteen  belonged  to  the  fourth  class — one  death. 

While  admitting  that  the  mortality  of  the  one  hundred  fourteen  cases  was 
not  low,  Olshausen  draws  attention  to  the  fact  that  they  were  the  most  serious  ones 
of  the  entire  one  thousand  five  hundred  fifty-five.  The  mortality  in  the  first 
group  was  high  because  in  eight  cases  multiple  peritoneal  abscesses  complicated  a 
fresh  peritonitis;  and  in  the  third  class  there  were  fifteen  cases  of  perforation  of  the 
intestine  with  seven  deaths. 

The  practice  of  Olshausen  is  amply  justified  by  the  results  he  has  achieved,  ex- 
cept in  two  series  of  cases,  namely,  those  complicated  by  multiple  peritoneal  abscesses, 
and  those  complicated  by  intestinal  or  vesical  injury.  In  both  of  these  conditions 
drainage  is  advisable. 

In  pelvic  surgery  experience  has  shown  that  drainage  is  indicated  under  the  fol- 
lowing instances: 

When  the  small  intestine,  the  rectum  or  the  sigmoid  has  been  injured  in  the 
separation  of  adhesions  and  there  is  any  doubt  as  to  the  security  of  the  sutures  clos- 
ing the  rent. 

When  a  large  amount  of  exudate  or  a  considerable  portion  of  an  abscess  sac 
must  be  left  behind. 

To  favor  hemostasis  and  to  provide  free  exit  in  case  of  extensive  oozing. 

Pelvic  drainage  is  made  by  preference  through  Douglas'  pouch.  At  the  con- 
clusion of  the  celiotomy,  the  pelvis  is  thoroughly  cleansed  by  sponging  with  moist 
gauze,  or  by  irrigation  and  dried  with  gauze  pads.  A  few  coils  of  gauze  are  then 
packed  into  Douglas'  pouch,  and  the  abdominal  incision  is  closed.  The  patient  is 
placed  in  the  lithotomy  position,  the  vagina  and  the  external  genitalia  are  thoroughly 
disinfected,  and  an  opening  is  made  into  the  pouch  of  Douglas  by  incising  the  poste- 
rior vaginal  wall  (Fig.  818).     Through  this  the  gauze  is  drawn  and  an  abundant 


720 


DRAIXAGE    IX   ABDOMINAL    AXD    PELVIC    SURGERY. 


perineal  dressing  is  applied  externally.  In  the  case  of  jpelvic  infla?7imatori/  disease 
which  follows  abortion  or  labor,  or  is  associated  with  extrauterine  pregnancy,  the 
infecting  organism  is  more  often  virulent  than  in  cases  unconnected  with  pregnancy. 
Cases  of  this  sort,  I  believe,  should  be  preferably  operated  upon  through  the  vagina. 
If  an  abdominal  operation  is  imperative,  great  pains  should  be  taken  to  protect  the 
general  peritoneal  cavity,  and  drainage  should  always  be  provided  through  Douglas' 
pouch. 


Fig.  818. — The  Ixstitutiox  of  Drainage  through  a  Posterior  Vagixal  Ixcisiox. 
The  operation  through  the  abdominal  incision  has  been  completed.  A  strip  of  gauze  is  coiled  in  Douglas' 
cul-de-sac,  and  the  celiotomy  wound  closed.  The  patient  is  placed  in  the  dorsal  position,  the  posterior  vaginal 
wall  is  retracted,  the  posterior  lip  of  the  cer\nx  is  pulled  upward  and  forward,  and  an  incision  is  made  into  the 
pouch  of  Douglas.  The  opening  should  be  dilated  and  the  end  of  the  gauze  strip  drawn  into  the  vagina.  Care 
must  be  observ^ed  that  the  posterior  vaginal  opening  is  free,  and  is  not  blocked  by  the  drain. 


After  the  vaginal  incision  of  a  pehic  abscess  or  a  hematocele  in  Douglas'  pouch, 
the  posterior  vaginal  opening  is  dilated  and  the  ca^^ty  is  snugly  filled  with  folds  of 
gauze.  When  pehic  drainage  is  indicated  after  panhysterectomy,  either  by  the 
abdominal  or  l^y  the  vaginal  route,  it  may  be  placed  through  the  opening  in  the  vault 
of  the  vagina.  Drainage  of  this  sort  should  not  be  disturbed  for  from  three  to  five 
days;  in  the  meantime  no  vaginal  douches  are  permissible,  and  the  ostium  vagina 
is  constantly  protected  with  a  sterile  dressing. 


DRAINAGE    OF    PARTICULAR    ORGANS    OR    PARTS.  721 

Vermiform  Appendix. — After  appendicectomy  for  acute  inflammatory  lesions 
when  there  is  no  abscess  formation,  but  the  intestine  surrounding  the  appendix  is  red 
and  injected  and  covered  with  flakes  of  lymph,  it  is  advisable,  observing  the  pre- 
cautions respecting  the  general  peritoneum  already  described,  to  introduce  several 
cigarette  drains,  either  through  the  original  or  through  a  lumbar  incision,  as  may  be 
most  convenient.  An  appendiceal  abscess  securely  walled  off  from  the  general  peri- 
toneum should  be  opened  by  an  incision  which  does  not  invade  the  general  peri- 
toneal cavity.  After  evacuation  the  sac  should  be  drained  by  a  cigarette  drain  made 
of  rubber  tubing  with  a  gauze  inlay. 

When  an  abscess  cannot  be  reached  extraperitoneally ,  before  evacuation  the  sur- 
rounding areas  must  be  well  protected.  The  appendix  is  looked  for,  and  removed 
if  readily  found;  no  prolonged  search  or  dissection,  however,  should  be  made  for  it. 
The  surfaces  which  formed  the  wall  of  the  abscess  sac  should  then  be  dried,  and  if 
not  too  extensive  or  inaccessible  wiped  with  a  formalin  (1 :  .500)  or  a  bichlorid  (1 :  500) 
solution ;  smaller  areas  should  be  touched  with  pure  carbolic  acid,  followed  imme- 
diately with  alcohol.  The  drain  should  be  placed  in  position  before  removing  the 
gauze  which  protects  the  general  peritoneum.  The  drain  may  often  with  advantage 
be  brought  out  through  a  stab  wound  in  the  loin,  directly  above  the  crest  of  the  ilium 
and  an  inch  and  a  half  behind  the  anterior  superior  spine.  This  incision  is  most 
suitable  for  cases  in  which  the  area  to  be  drained  lies  to  the  right  of  the  colon  or  be- 
neath it.  If  the  infected  area  lies  to  the  inner  side  of  the  colon  or  near  the  pelvic 
brim,  one  drain  should  be  brought  out  through  the  incision  and  another  should  be 
placed  through  a  suprapubic  incision  to  the  bottom  of  the  pelvis.  When  an  abscess 
has  actually  invaded  the  female  pelvis,  it  should  be  drained  by  an  incision  through 
Douglas'  pouch.       A  pararectal^  or  a  rectal  incision  has  been  recommended   in 

^  Deaver  and  Ross  (Deaver,  John  B.,  and  Ross,  Geo.  C:  "The  Mortahty  of  Appendicitis," 
Jour.  Amer.  Med.  Assoc,  1901,  vol.  xxxvii,  p.  1898)  give  the  following  as  the  most  common 
positions  of  appendical  abscess: 

1.  Behind  the  cecum  and  between  the  layers  of  the  mesocolon.  This  is  the  most  common 
and  is  attended  by  a  high  rate  of  mortality,  because  of  the  tendency  to  gangrene  and  necrosis 
of  the  cecum  from  an  interference  with  its  blood-supply,  post-peritoneal  infection,  lymphadenitis, 
phlebitis,  and  pylephlebitis. 

2.  Immediately  beneath  the  parietal  peritoneum  confined  by  the  cecum,  the  coils  of  the  small 
intestine,  the  omentum,  the  appendix,  the  peritoneum,  and  a  mass  of  inflammatory  lymph.  In 
this  variety  the  mortality  is  much  lower,  and  the  question  of  removing  the  appendix  arises  most 
often. 

3.  Pelvic  collections  of  pus.  This  is  a  most  favorable  location,  but  it  is  frequently  unsuspected 
or  overlooked. 

4.  Near  the  median  line  and  to  the  mid-line  of  the  cecum.  A  fatal  issue  is  exceedingly  likely. 
This  variety  is  most  apt  to  be  connected  with  secondary  collections,  and  it  is  difficult  and  fre- 
quently impossible  to  treat  such  an  abscess  without  infecting  the  general  peritoneum. 

5.  The  infection  is  free  in  the  general  peritoneal  cavity,  and  practically  all  such  cases  are  fatal 
unless  operation  is  performed  very  early. 

2  E.  M.  Sutton:  ("Peritoneal  Operation  for  Perforative  Appendicitis  with  Abscess  in  the 
Cul-de-sac,"  Jour.  Amer.  Med.  Assoc,  vol.  xxx,  June  18,  1898,  p.  1438)  describes  the  plan  he  used 
for  draining  an  abscess  of  the  pelvis  in  a  male.  A  horseshoe  incision  was  made,  beginning  at  a 
point  mid-way  between  the  tuber  ischii  and  the  anus,  extending  to  the  bulbous  portion  of  the 
urethra,  and  from  there  to  a  similar  point  on  the  opi^osite  side.  The  external  hemorrhoidal  nerve 
and  artery  were  pushed  back,  and  the  transversus  perinei.  with  the  bulbous  portion  of  the  urethra, 
were  pushed  forward.  The  fibers  of  the  external  sphincter  were  incised  transversely  at  their  junc- 
tion with  the  bulbo-cavernosus  muscles.  The  deep  fascia  was  also  incised  transversely  where  it 
dips  down  to  join  the  pelvic  fascia,  separating  the  levator  ani  muscle,  reaching  the  prostate  and 
pushing  it  forward,  and  continuing  the  dissection  back  and  up  to  the  cul-de-sac. 
VOL.  II — 46 


722 


DRAINAGE   IN   ABDOMINAL   AND    PELVIC    SURGERY. 


Fig.  819. — Drainage  of  the 
Gall-bladder. 
A  piece  of  rubber  tubing  is 
secured  by  means  of .  a  catgut 
suture  to  one  of  the  edges  of  the 
incision  in  the  gall-bladder. 


persons  of  the  opposite  sex,  but  in  most  cases  is  inadmissible  for  several  reasons. 

A  rectal  incision  is  objectionable  on  general  principles 
and  in  certain  cases  must  add  an  element  of  danger 
from  infection.  In  exceptional  cases  an  appendiceal 
abscess  occupying  the  pelvis  has  been  successfully 
opened  and  drained  through  the  rectum. 

A  pararectal  incision,  unless  carefully  performed,  is 
capable  of  much  harm,  and  because  of  the  time  it 
would  consume  would  be  entirely  unjustifiable.  Few 
surgeons  would  jeopardize  the  life  of  an  already  des- 
perately sick  patient  in  order  to  drain  the  pelvis  in  this 
way.  A  better  plan  is  to  assist  the  action  of  supra- 
pubic drainage  by  rectal  massage  at  regular  intervals. 
A\Tiatever  exits  are  chosen,  the  incision  should  be 
free,  and  care  should  be  taken  that  the  drainage  mate- 
rial does  not  block  it. 

Gall-bladder  and  Gall-duct. — It  is  ahvays  advis- 
able to  drain  the  gall-bladder  after  cholelithotomy.  The 
usual  way  is  by  means  of  rubber  tubing  held  in 
place  by  a  catgut  stitch,  which  is  absorbed  by  the 
time  drainage  is  no  longer  desirable.     A  better  plan 

is  to  use  a  mushroom  catheter  (Fig.  550),  which  can  be  maintained  in  position 

without  being  sutured,  and  removed  at  any  time. 

Irrespective   of    the    one   selected,   care    should    be 

taken   by  means   of    suitable    stitches    to   close   the 

incision  in  the  gall-bladder  snugly,  but  not  tightly, 

about  the  drain  (Fig.  821),  inverting  the  cut  edges 

so  that  the  serous  surfaces  are  in  apposition.     The 

gall-bladder  is  closely  sutured  also  to  the  parietal 

peritoneum,  but  not  to   the  muscle  or  fascia  of  the 

abdominal  wall.      The  catheter  or  the  tube  should 

be  long  enough  to  project  7  or  8  inches  beyond  the 

abdominal  incision,  and  at  its  outer  extremity  an- 
other piece  of  tubing  should  be  attached,  by  means 

of   a   glass  connection,  and  carried  over  to  a  glass 

receptacle  suspended  at  the  side  of  the  bed.      By 

this  means,  the  rate   and  quality  of  the  discharge 

may  be  constantly  observed,  there  is  practically  no 

soiling  of  the  incision,  and  the  patient  is  much  more 

comfortable.     If  the  gall-bladder  has  been  infected, 

it  is   useful,   after   several   days,   to  gently  irrigate 

through  the  tube  with  a  weak  solution  of  protargol,  10  per  cent.,  or  nitrate  of 

silver,  1 :  3000. 


Fig.  820. — Draixage  of  the  Gall- 
bladder. 
The  edges  of  the  incision  are  in- 
verted and  united  above  and  below 
the  tube  by  means  of  a  running  cat- 
gut suture. 


DRAINAGE    OF    PARTICULAR    ORGANS    OR    PARTS. 


723 


If  the  gall-bladder  is  infected  or  the  surrounding  parts  have  been  soiled,  several 
cigarette  drains  should  be  placed  in  the  wound  below  its  attachment  to  the  gall-bladder. 
These  should  reach  the  foramen  of  Winslow  and  the  renal  fossa  on  the  rio-ht  side. 

After  simple  choledochotomy  the  incision  in  the  common  duct  should  be  neatly 
closed  and  drainage  provided  through  the  gall-bladder.  A  cigarette  drain,  however, 
should  always  be  placed  below  the  line  of  sutures  in  the  common  duct.  When 
for  any  reason  the  presence  of  small  calculi  in  the  hepatic  duct  is  suspected,  rubber 
tube  drainage  of  the  hepatic  duct  should  be  instituted. 

Kehr's^  technic  for  drainage  of  the  hepatic  duct  is  as  follows :  After  the  stones 
have  been  removed  a  soft-rubber  tube  is  inserted  through  the  common  duct  incision 
upward  into  the  hepatic  duct.  Sometimes  the  bifurca- 
tion of  the  hepatic  duct  is  so  low  down  that  the  tube 
can  be  introduced  for  only  a  short  distance.  A  catgut 
suture  is  used  to  fasten  the  tube  into  place.  Gauze 
wicking  is  placed  about  the  tube,  and  neither  are  dis- 
turbed for  two  weeks.  Before  that  time,  according  to 
Berger,  bile  will  be  flowing  freely  into  the  intestine. 

The  importance  of  draining  the  gall-bladder  after 
an  operation  on  the  common  duct  has  been  noted  by 
Coley.^  He  agrees  with  Quenu  that  the  common  duct 
should  never  be  sutured  unless  the  gall-bladder  is 
drained,  and  indorses  Robson's  plan  of  suturing  the 
duct  and  draining  the  bladder  as  the  ideal  form  of 
procedure.  The  IMayos^  say  that  it  is  quite  unneces- 
sary, as  a  rule,  to  suture  the  common  duct  or  to  intro- 
duce a  rubber  tube  for  the  purpose  of  draining  the 
hepatic  duct.  Instead  they  provide  drainage  for  the 
common  duct  incision  and  drain  the  gall-bladder,  ex- 
cept in  the  simplest  cases. 

Hepatic  Drainage  when  the  Biliary  Tract  is 
Infected. — Deaver*  remarks  that  hepatic  drainage 
must  be  provided  in  all  infected  cases,  through  the 
gall-bladder,   the  common  duct,   or  the  hepatic  duct. 

Abscess  of  the  liver  is  prevented  and  pancreatitis  is  relieved  by  prompt  drainage. 
Bile  is  always  to  be  regarded  as  a  septic  fluid,  capable  of  causing  peritonitis. 
After  choledochotomy,  even  though  there  is  no  clinical  evidence  of  infection,  and  it 
is  certain  that  suture  of  the  incision  will  not  constrict  the  lumen  of  the  duct,  drain- 
age of  the  area  should  be  provided,  for  fear  of  leakage. 

'  Berger,  Erich:   "Die  Hepaticusdrainage,"  Archiv  f.  klin.  Chirurg.,  1903,  Bd.  Ixix,  S.  299. 
^  Coley,  W.  B.:   "Progressive  Medicine,"  1899,  p.  61. 

3  Mayo,  W.  J.:    "A  Study  of  534  Operations  on  the  Gall-bladder  and  Bile  Passages,"  etc., 
Boston  Med.  and  Surg.  Jour.,  1903,  vol.  cxlviii,  p.  545. 

*  Deaver,  John  B.:    "Hepatic  Drainage  in  Infection  of  the  Biliary  Tract,"  N.  Y.  Med.  Jour.. 
1904,  vol.  Ixxix,  p.  147. 


-•Vf(-^L-'Z^ 


Fig. 


821. — Drainage  of  the 
Gall-bladder. 
The  institution  of  drainage 
completed  and  the  margin  of  the 
gall-bladder  incision  united  above 
and  below  the  tube,  so  that  the 
serous  surfaces  are  in  apposition. 
The  catgut  suture  holding  the  tube 
in  place  is  absorbed  at  the  end  of 
two  weeks  and  the  tube  may  then 
be  readily  removed.  All  of  these 
sutures  should  be  of  catgut  pref- 
erably. 


724  DRAINAGE    IN   ABDOMINAL   AND    PELVIC    SURGERY. 

The  best  method  of  draining  the  common  and  hepatic  ducts  is  that  employed 
by  Martin  and  Carnett.  A  rubber  tube  of  suitable  length  is  bisected  for  the  dis- 
tance of  an  inch  at  one  extremity.  The  two  flaps  thus  formed  are  bent  backward 
on  the  tube  at  right  angles  and  secured  in  this  position  by  a  stitch  which  embraces 
the  angle.  The  tube  is  now  introduced  into  the  common  duct,  one  of  the  flaps 
being  passed  into  the  duct  above  and  the  other  below  the  incision.  By  this  plan 
the  lumen  of  the  common  duct  is  practically  unobstructed,  and  the  bile  takes  its 
normal  course  or  comes  out  through  the  tube. 

Drainage  when  the  Cystic  Duct  is  Obstructed  or  the  Gall-bladder 
HAS  BEEN  Removed. — If  the  cystic  duct  is  obstructed,  the  gall-bladder  is  excised 
and  a  drainage-tube  is  inserted  into  the  end  of  the  cystic  duct.  If  the  gall-bladder 
has  been  previously  removed,  the  stump  of  the  cystic  duct  is  opened.  In  case  none 
of  the  cystic  duct  remains,  or  if  it  is  so  diseased  that  it  is  more  or  less  impervious, 
drainage  of  the  hepatic  duct  should  be  inaugurated. 

Stomach. — Most  of  the  operations  on  the  stomach  require  no  drainage.  After 
operation  for  a  penetrating  wound,  it  is  advisable,  usually,  to  insert  a  strip  of  gauze 
down  to  the  line  of  suture.  If  the  wound  is  clean-cut  and  there  is  but  little 
bruising  of  the  surrounding  wall,  this  may  be  omitted. 

Following  operation  for  a  perforating  ulcer,  drainage  will  be  indicated  at  the  site 
of  the  lesion  and  elsewhere,  if  there  has  been  extensive  soiling  of  the  peritoneum. 
Drainage  may  not  be  required  if  the  case  is  operated  on  within  six  hours.  When 
twelve  hours  have  elapsed,  however,  it  is  safer  to  make  use  of  it.^ 

Pancreas. — Drainage  should  be  employed  in  connection  with  every  form  of 
surgical  operation  on  the  pancreas.  The  only  exceptions  to  this  rule,  according  to 
Moynihan,  are  cases  in  which  no  pancreatic  fluid  has  escaped  during  the  procedure 
and  the  peritoneal  incision  used  to  expose  the  pancreas  has  been  closed  by  suture. 

General  Peritoneum. — Nearly  all  surgeons  agree  that  drainage  is  a  necessity  in 
general  peritonitis.  There  is  some  difference  of  opinion,  however,  as  to  the  extent 
to  which  it  should  be  employed.  The  condition  of  the  patient  must  be  the  guide  to 
the  amount  of  operative  manipulation.  In  the  most  serious  cases  when  general 
anesthesia  is  undesirable  an  incision  should  be  made  under  local  anesthesia,  the 
original  site  of  infection  should  be  removed  if  possible,  a  gauze  and  rubber  drain 
of  large  caliber  should  be  placed  in  the  wound  and  an  additional  one  inserted  to  the 
bottom  of  the  pelvis.  When  the  condition  of  the  patient  permits,  it  is  advisable  to 
wash  out  the  general  peritoneal  cavity  and  introduce  drainage  at  several  points. 
The  original  site  of  the  infection  should  be  drained  through  the  primary  incision,  if 
the  latter  is  made  directly  over  it.  If  the  first  incision  lies  at  some  distance,  a  second 
one  is  required. 

There  are  certain  areas  in  the  abdominal  cavity  where  fluids  are  apt  to  collect, 
and  pains  should  be  taken  to  provide  efficient  drainage  for  them  (Fig.  822).  An 
incision  in  the  flank  on  both  sides  will  be  required  to  drain  the  renal  fossfe.     In 

^  Moynihan,  B.  G.  A.:   "Abdominal  Operations,"  p.  116,  Phila.  and  London,  1905. 
^  Loc.  cit.,  p.  596. 


DRAINAGE    OF    PARTICULAR    ORGANS    OR   PARTS. 


725 


the  female  the  pelvis  is  readily  drained  through  the  pouch  of  Douglas.  In  the 
male  cigarette  drains  may  be  introduced  to  the  bottom  of  the  pelvis  through  a  low 
median  abdominal  incision.  The  head  of  the  bed  should  be  elevated  to  favor  the 
flow  of  septic  material  toward  the  pelvis. 

The  treatment  of  general  peritonitis  is  so  disappointing  in  its  results,  and  the 
limitations  of  any  form  of  drainage  are  so  manifest,  that  some  surgeons  use  no  more 
than  a  comparatively  small  drain  in  the  original  incision.     Blake,^  in  1903,  reported 


Fig.  822. — Abdomen  Showing  Three  Major  Foss^,  Right  and  Left  Abdominal,  and  Pelvic. 
The  abdominal  fossae  are  subdivided  into  renal  and  iliac.     In  these  fossa;  fluids  are  prone  to   accumulate  with  the 

patient  in  recumbent  position. 

a  series  of  general  peritonitis  cases,  some  of  which  were  treated  with  drainage  and 
some  without  it.  Although  he  admits  that  sweeping  conclusions  cannot  be  drawn 
because  the  series  was  small,  it  is  of  some  significance  to  note  that  there  were  about 
an  equal  number  of  recoveries  in  the  two  classes,  the  advantage  even  resting  slightly 
with  the  undrained  cases.  He  says:  "  I  was  formerly  a  warm  advocate  of  abundant 
drainage;  later,  I  became  convinced  of  the  utter  impossibility  of  draining  every  part 


1  Blake,  Jos.  A.: 
Surg.  Assoc,  1903. 


"The  Treatment  of  the  Peritoneum  in  Diffuse  Peritonitis,"  Trans.  Amer. 


726  DRAINAGE    IX    ABDOMINAL   AND    PELVIC    SURGERY. 

of  the  peritoneal  cavity,  for  it  was  evident  that  the  drain  was  soon  isolated  by  ad- 
hesions; so  I  next  confined  myself  to  the  drainage  of  the  field  of  operation;  and  then 
perceiving  that  the  other  similarly  affected  regions  of  the  peritoneum  took  care  of 
themselves,  I  omitted  drainage  almost  entirely  and  only  employed  it  when  the 
presence  of  a  non-absorbable  amount  of  necrotic  tissue  or  hemorrhage  de- 
manded it." 

Although  Fowler^ uses  drainage  in  the  great  majority  of  cases, he  says:  "I  would 
also  state  that  there  are  certain  cases  of  diffuse  septic  peritonitis  which  may  be  safely 
closed  without  drainage.  These  are  cases  in  which  there  are  no  necrotic  areas,  and 
in  which  the  serous  covering  of  the  intestine  is  not  bHstered  or  desquamated  or 
swollen  or  infiltrated.  It  is  my  firm  conviction,  however,  that  cases  for  complete 
closure  should  be  carefully  selected,  and  can  only  be  safely  selected  by  an  operator 
of  wide  and  constant  experience.  No  more  striking  evidence  could  be  adduced  in 
support  of  drainage  than  the  frequency  with  which  secondary  abscesses  form  in 
these  desperate  cases.  They  do  not  form  because  of  the  drainage,  but  in  spite  of  it, 
and  often  can  be  easily  opened  through  the  drainage  tract." 

Blake^  has  recently  reported  a  series  of  ninety-nine  cases  of  diffuse  suppurative 
peritonitis;  seventy-eight  followed  appendicitis;  the  mortality  was  19.27  per  cent. 
Of  fifteen  who  died,  seven  were  not  drained;  eight  were  drained.  Of  the  patients 
who  recovered,  thirty-one  were  not  drained,  twenty-eight  were  drained  to  the  stump 
of  the  appendix,  and  four  were  drained  to  the  pelvis.  The  author  also  reports 
thirteen  cases  of  diffuse  peritonitis,  caused  by  perforation  of  the  stomach  or  of  the 
upper  intestine.  There  were  four  deaths,  a  mortality  of  30.7  per  cent.  Of  the 
four  patients  who  died,  two  were  not  drained  and  two  were  drained  to  the  suture 
line.  Of  the  nine  recoveries,  four  were  not  drained,  and  four  were  drained  from 
the  suture  line  of  the  stomach,  and  one  was  drained  from  the  pelvis.  In  eight  cases 
of  diffuse  peritonitis  following  perforation  of  a  typhoid  ulcer,  four  died  and  all  four 
had  been  drained.     Of  the  four  recovering,  drainage  was  employed  in  two. 

Blake's  principles  of  operative  treatment  in  such  cases  are : 

1.  To  remove  the  origin  of  the  inflammation  as  rapidly  as  possible  through 
a  small  incision. 

2.  To  wash  out  and  irrigate  the  peritoneal  cavity. 

3.  To  use  as  little  drainage  as  possible  and  not  to  attempt  to  drain  the  general 
peritoneal  cavity. 

In  estimating  the  value  of  Blake's  comparison  of  drained  with  undrained  cases, 
it  should  be  stated  that  he  invariably  drains  the  wound.  The  small  drain  which 
he  uses  for  this  purpose  evidently  projects  slightly  into  the  peritoneal  cavity  beneath 
the  incision,  so  that,  to  some  extent  at  least,  drainage  is  used  in  all  of  his  cases,  and 
the  incision  is  never  tightly  closed. 

He  says:   "It  is  my  impression  that  our  patients  have  made  smoother  recoveries 

1  Fowler,  R.  S.:  New  York  State  Jour,  of  Med.,  Oct.,  1907,  p.  401. 

2  Blake,  Joseph  A.:  "The  Treatment  of  Diffuse  Suppurative  Peritonitis,"  Amer.  Jour.  Med. 
Sci.,  March,  1907,  cxxxiii,  454. 


DRAINAGE    OF    PARTICULAR    ORGANS    OR    PARTS.  727 

by  the  omission  of  drainage  when  possible,  and  I  cannot  look  back  with  regret  upon 
the  occasions  when  I  have  omitted  it.  On  the  other  hand,  it  is  impossible  to  draw 
hard  and  fast  lines  as  to  the  method  of  treatment  in  these  cases,  and  judgment  must 
be  continually  exercised.  Some  need  drainage,  some  do  not.  Some  seem  to  do 
better  with  irrigation,  others  get  well  without  irrigation  or  drainage,  and  some  die 
whether  drained  or  not,  washed  or  unwashed." 

The  treatment  of  a  case  preparatory  to  the  institution  of  drainage  is  also  a  moot 
point.  Finney^  advised,  practised,  and  finally  abandoned  eventration  of  the  intestines 
with  thorough  cleansing  of  the  peritoneal  cavity  and  the  loops  of  bowel  with  gauze 
and  saline  solution.  The  worst  coil  of  bowel  was  replaced  last,  left  near  the  in- 
cision, and  packed  about  with  strips  of  gauze.  He  did  not  think  favorably  of 
irrigation  under  all  circumstances.  Most  surgeons  believe  in  irrigation  without 
evisceration.  Among  those  who  have  expressed  themselves  as  favorable  to  this 
plan  may  be  mentioned  McCosh^  and  Dwight,^  the  latter  reporting  a  series  of  thirty- 
five  cases  with  fifteen  recoveries.  Dwight  believes  in  irrigating  until  the  solution 
returns  clear,  and  then  placing  three  or  four  gauze  drains  in  different  parts  of  the 
abdomen. 

Murphy,*  of  Chicago,  reports  forty-eight  consecutive  operations  for  general 
suppurative  peritonitis  resulting  from  a  perforation  in  some  part  of  the  gastro-intesti- 
nal  tract.  There  were  two  deaths;  one  from  double  pneumonia  on  the  sixth  post- 
operative day,  another  from  intestinal  obstruction  four  and  one-half  days  after  the 
operation.     Drainage  and  continuous  enteroclysis  were  used  in  all. 

In  the  discussion  of  a  paper  which  he  read  before  the  American  Association  of 
Obstetricians  and  Gynecologists  in  1906,^  he  said  that  he  considered  an  early  oper- 
ation the  precious  element  in  the  treatment  of  these  cases.  If  the  patient  has 
received  a  sufficient  dose  of  toxins,  death  will  occur  no  matter  what  procedure 
is  adopted.  Nothing  but  a  timely  operation  will  prevent  this  intoxication.  INIurphy 
avoids  handling  the  intestines  and  the  viscera  as  much  as  possible.  He  closes  the 
perforation  wherever  it  may  be,  and  introduces  drainage  after  the  method  of  Fowler. 

Continuous  enterocly.sis  is  a  most  valuable  addition  to  the  after-treatment.  For 
this  purpose  the  ordinary  vaginal  douche  tip  with  three  openings  should  be  used, 
so  that  the  water  can  flow  in  through  one  and  the  gas  pass  out  through  the  others. 
If  a  tip  with  a  single  opening  is  used,  gas  will  not  bubble  back  into  the  reservoir. 
The  evacuation  of  gas  in  this  manner  is  important;  otherwise  when  the  patient 
attempts  to  expel  the  gas  through  the  anus  the  salt  solution  will  not  be  retained. 

The  elevation  of  the  reservoir  should  be  from  four  to  six  inches  above  the  level 
of  the  anus.     The  nurse  should  be  instructed  to  watch  the  patient  closely  and  not 

'  Finney,  J.  T.  M. :  "Surgical  Treatment  of  Perforating  Typhoid  Ulcer,"  Ann.  Surg.,  1897,  xxv, 
233. 

'  McCosh,  Andrew  J.:  "The  Treatment  of  General  Peritonitis,"  Medical  News,  1905,  Ixxxvii, 
865. 

^Dwight,  Ed.  W.:  "General  Purulent  Peritonitis,  with  a  Report  of  Thirty-five  Cases,  of 
which  Fifteen  Recovered,"  Med.  and  Surg.  Reports  Boston  City  Hosp.,  1902.  p.  88. 

^  Personal  Communication. 

^  Murphy,  John  B.:  Trans.  Amer.  Assoc.  Obstet.  and  Gynecol.,  1906,  vol.  xix,  p.  183. 


728  DRAINAGE    IX   ABDOMINAL    AND    PELVIC    SURGERY. 

allow  any  more  than  one  and  one-half  pints  of  the  saline  solution  to  be  introduced 
during  forty  minutes  to  one  hour.  The  rubber  tube  connecting  the  douche  tip  and 
the  reservoir  can  be  strapped  to  the  leg  of  the  patient  with  adhesive  plaster,  the 
reservoir  being  suspended  at  the  head  of  the  bed  and  kept  warm  with  a  hot-water 
bottle.     (See  Fig.  622.) 

There  need  be  no  irritation  of  the  rectum,  and  the  patient  often  goes  to  sleep 
while  the  irrigation  is  being  carried  on.  The  tube  is  not  taken  out  for  days.  The 
rate  of  flow  is  not  controlled  by  compressing  the  tube  with  forceps,  but  by  the  degree 
of  elevation  of  the  reservoir. 

The  abdominal  drains  are  kept  in  place  until  there  is  a  cessation  of -the  discharge. 
The  length  of  time  varies  considerably  in  different  patients.  It  may  be  a  week,  it 
may  be  considerably  longer. 

Among  the  best  results  which  have  been  reported  are  those  of  the  Fowlers. 
Thev  believe  in  irrigation,  drainage,  and  the  use  of  a  semi-recumbent  position, 
which  has  been  given  their  name.  The  Fowler  position^  causes  peritoneal  fluids 
to  gra^dtate  to  the  pelvis,  and  antagonizes  absorption  in  the  diaphragmatic  area. 
The  large  stomata  of  the  peritoneum  covering  the  diaphragm  favor  the  transference 
of  septic  peritoneal  fluids  in  its  ^^cinity  to  the  circulation,  with  resulting  distant 
infection,  or  general  intoxication,  or  both.  On  the  other  hand,  the  gra^^tation  of 
septic  fluids  to  the  pelvic  cavity  results  in  an  environment  unfavorable  to  their 
absorption.  The  anatomic  pecuHarities  of  the  pelvic  peritoneum  are  such  that, 
as  is  well  known,  "septic  conditions  of  the  most  pronounced  character  may  exist 
for  a  long  time  without  grave  danger  to  the  individual." 

In  1904  a  report  was  made  of  one  hundred  cases  of  diffuse  septic  peritonitis 
treated  by  the  Fowler  methods,  with  a  recovery  of  67  per  cent.^ 

Another  report  was  made  in  1907.^  One  hundred  and  forty-four  cases  were 
reported;  there  were  59  per  cent,  of  recoveries.  These  results  are  strikingly  good, 
and  prove,  I  believe,  that  for  the  majority  of  cases  of  disuse  peritonitis  the  folloicing 
-plan  of  treatment  is  the  best: 

1.  A  small  incision  and  the  avoidance  of  eventration. 

2.  The  removal,  if  possible,  and  a  thorough  cleansing  of  the  primary  focus  of 
infection. 

3.  The  evacuation  and  cleansing  of  all  accessory  ca\dties  and  the  pelvis  before 
washing  out  the  peritoneal  ca\Tity. 

4.  A  rapid  systematic  flushing  of  the  peritoneal  ca\nty  with  peroxid  and  soda 
solution  fperoxid  of  hydrogen  and  a  saturated  solution  of  bicarbonate  of  soda,  equal 
parts)  followed  by  hot  saline  solution. 

1  Fowler,  G.  R.:  "The  Toilet  of  the  Peritoneum  in  Appendicitis,"  Trans.  Amer.  Surg.  Assoc, 
1903,  xxi,  23. 

2  Fowler,  R.  S. :  "Results  in  Diffuse  Septic  Peritonitis  Treated  by  the  Elevated  Head  and  Trunk 
Position,"  Med.  News,  May  28,  1904. 

3  Fowler,  R.  S.:  "The  Treatment  of  Diffuse  Septic  Peritonitis  Following  Appendicitis,"  New- 
York  Jour,  of  Med.,  vol.  vii,  No.  10,  Oct.,  1907,  p.  401. 


DRAINAGE    OF    PARTICULAR    ORGANS    OR    PARTS.  729 

5.  The  continuance  of  the  sahne  flushing  until  the  sutures  are  placed  and  for 
the  most  part  tied. 

6.  The  provision  of  proper  drainage  for  the  pelvis,  either  by  means  of  a  large 
glass  tube  containing  a  capillary  drainage  strip  emerging  through  the  lower  angle 
of  the  wound,  or  in  the  female  by  a  large-caliber  rubber  tube  filled  with  wicking 
passed  through  a  posterior  colpotomy  incision. 

7.  The  drainage  of  accessory  abscess  cavities  with  gauze  or  wicking. 

8.  The  elevation  of  the  head  of  the  bed  to  accelerate  the  drainage  of  septic  fluids 
into  the  pelvis. 

The  head  of-  the  bed  is  elevated,  7,  13,  or  20  inches;  the  lowest  elevation  is  used 
during  the -first  few  hours;  after  that  the  highest,  except  in  cases  of  nervous  shock. 

During  elevation  of  the  head  of  the  bed,  the  patient  is  prevented  from  slipping 
downward  by  a  folded  pillow  placed  against  the  buttocks  and  held  there  by  a  stout 
bandage  passed  through  the  fold  of  the  pillow  and  tied  at  the  head  of  the  bed.  In 
this  way  the  knees  are  flexed  on  the  abdomen  and  the  abdominal  wall  is  relaxed, 
adding  to  the  comfort  of  the  patient.  A  saline  enema  is  repeated  four  to  six  times 
at  three-  to  four-hour  intervals  or  continuous  enteroclysis  according  to  Murphy's 
plan  (page  727)  should  be  used.  If  gas  is  not  passed  freely  by  the  bowel,  a  high 
enema  of  turpentine  and  ox-gall  is  used.  Fluids  are  given  by  the  mouth  ad  libi- 
tum. The  drainage-tube  is  dressed  separately  with  a  hood  of  rubber  dam,  and 
its  contents  are  evacuated  and  fresh  gauze  applied  every  four  hours. 

In  making  an  estimate  of  the  value  of  drainage  and  the  various  plans  of  treatment 
of  diffuse  peritonitis,  it  must  be  kept  in  mind  that  all  cases  spoken  of  as  general 
peritonitis  are  by  no  means  alike,  either  in  extent,  form,  or  cause.  A  really  general 
peritonitis  involves  the  entire  peritoneal  cavity,  including  that  of  the  lesser  omentum. 
Deaver  drew  attention  to  this  fact  in  1898,  and  Hartley,  in  1899,  expressed  the  same 
opinion.  "Many  cases,"  Deaver  says,  "are  reported  in  the  literature  as  recoveries 
from  general  purulent  peritonitis,  but  from  my  experience  I  am  led  to  think  that 
there  was  probably  some  error  in  the  diagnosis  and  that  the  cases  were  probably  a 
very  extensive,  but  nevertheless  a  localized  peritonitis." 

In  order  to  secure  an  accurate  idea  of  the  comparative  value  of  different  plans 
of  treatment,  it  would  be  wise  in  reporting  them  to  divide  peritonitis  cases  into 
the  three  classes  suggested  by  Blake.  They  are:  (l)  An  abscess  with  limiting 
adhesions.  (2)  A  spreading  peritonitis  in  which  there  is  no  actual  localization 
of  the  process  by  adhesions  or  gravitation,  but  in  which  there  are  ascertainable 
limits  to  the  infection.  (3)  Cases  of  general  peritonitis  in  which  no  part  of  the 
peritoneum,  possibly  excepting  the  lesser  sac,  can  be  demonstrated  as  free  from  the 
invasion. 

Whatever  treatment  is  adopted,  should  be  selected  for  the  individual  case. 
AVhile  in  one  instance  no  more  than  a  hasty  incision  and  the  introduction  of  a 
drainage-tube  may  be  permissible,  in  another  the  most  elaborate  technic  of  dis- 
infection and  drainage  would  be  justified. 

Kidney. — A  paranephric  abscess  demands  free  drainage.     After  nephropexy 


730  DRAINAGE    IN   ABDOMINAL   AND    PELVIC    SURGERY. 

and  aseptic  cases  of  nephrotomy  or  nephrolithotomy  when  the  kidney  incision  is 
clean-cut  and  can  be  nicely  approximated  no  drainage  is  required.  If  the  incision 
is  ragged  the  paranephric  tissues  should  be  drained.  When  infection  is  present  and 
when  it  is  desirable  to  drain  the  pelvis  because  of  obstruction,  cigarette  drains  of 
rubber  tubing  and  gauze  should  be  introduced  through  the  kidney  incision  as  far  as 
the  pelvis;  at  the  same  time  several  cigarette  drains  should  be  placed  in  the  para- 
nephric areas. 

After  ureterotomy  for  stone  or  stricture,  a  drain  should  be  passed  to  the  neighbor- 
hood of  the  line  of  sutures. 

Bladder. — Drainage  of  the  female  bladder  is  required  after  operation  for  vesical 
stone  and  fistula,  and  is  readily  accomplished  by  the  introduction  of  a  self-retaining 
(mushroom)  catheter  through  the  urethra. 

If  the  bladder  is  highly  inflamed  and  complete  and  constant  drainage  is  desired, 
the  organ  should  be  opened  at  its  base  by  an  incision  through  the  anterior  vaginal 
wall.  The  vesicovaginal  fistula  thus  made  is  maintained  by  the  introduction  of  a 
mushroom  catheter  or  by  uniting  the  vesical  to  the  vaginal  mucosa. 

Suprapubic  vesical  drainage  is  often  required  in  the  male,  and  on  some  unusual 
occasions  might  be  desirable  in  the  female.  A  rubber  tube  should  be  secured  in  the 
vesical  incision  and  connected  with  a  glass  receptacle  at  the  side  of  the  bed  in  the 
manner  described  for  drainage  of  the  gall-bladder.  In  such  cases  it  is  usually  ad- 
visable to  place  one  or  two  cigarette  drains  in  the  space  of  Retzius. 

Intestine. — In  certain  cases  of  ileus  when  the  patient  is  so  ill  that  an  operation 
for  permanent  relief  cannot  be  undertaken,  the  bowel  should  be  drained  above  the 
seat  of  obstruction.  After  suturing  the  intestine  at  this  point  to  the  parietal  peri- 
toneum and  making  an  enterotomy  incision  a  rubber  tube  should  be  passed  into  the 
bowel  and  held  there  by  a  purse-string  suture  in  the  outer  intestinal  coats  and  one 
transverse  suture  which  passes  through  the  tube.  The  outer  extremity  of  the  rubber 
tube  should  be  conducted  over  the  side  of  the  bed  to  a  suitable  receptacle.  After 
the  symptoms  have  been  relieved  and  the  patient  is  stronger,  an  operation  to  re- 
lieve the  obstruction  may  be  undertaken;  at  that  time  the  enterotomy  incision 
should  be  closed. 

POST-OPERATIVE  CARE  OF  DRAINAGE. 

Gauze  packing  introduced  for  the  purpose  of  controlling  hemorrhage  should  be 
removed  within  twenty-four  to  thirty-six  hours.  Uterine  drains  should  be  removed 
at  the  end  of  twenty-four  to  thirty-six  hours. 

Other  gauze  drains  should  not  be  disturbed  until  the  fifth  post-operative  day. 
There  are  some  exceptions  to  this  rule;  for  example,  if  the  drain  is  quite  superficial 
or  if  it  is  a  question  whether  there  is  any  infection  and  the  necessity  for  its  original 
use  was  a  matter  of  doubt,  the  gauze  may  be  removed  at  the  end  of  twenty-four  to 
thirty -six  hours. 

Cigarette  drains  may  be  taken  out  earlier  than  drains  composed  entirely  of  gauze, 
because  there  is  less  danger  of  breaking  up  protecting  adhesions. 


POST-OPERATIVE    CARE    OF   DRAINAGE.  731 

Drainage  must  always  be  maintained  for  a  comparatively  longer  time  if  tissue 
of  doubtful  vitality  has  been  left  in  the  operative  area.  Such  drains,  whatever  their 
form,  should  remain  in  position  for  at  least  five  days  and  then  be  slowly  removed. 
A  little  is  taken  out  each  day  without  using  force,  so  that  the  material  is  extracted 
gradually  as  it  loosens  from  its  attachments.  Painstaking  asepsis  is  required  in  all 
of  these  manipulations.  After  the  fifth  day  the  gauze  may  be  moistened  with  sterile 
water  to  facilitate  its  removal.  Solutions  should  never  be  injected  into  the  drainage 
tract,  except  in  the  case  of  an  encapsulated  collection,  when  it  may  be  useful  to 
maintain  tubular  drainage.  The  use  of  peroxid  of  hydrogen  in  abdominal  drainage 
tracts  is  dangerous.  For  cleansing  purposes  nothing  is  more  efficient  than  salt 
solution. 

In  cases  of  pancreatitis  or  infection  of  the  biliary  ducts  it  is  desirable  to  maintain 
drainage  until  the  symptoms  of  the  trouble  have  entirely  disappeared  and  the  bile 
becomes  sterile. 

When  nephrotomy  or  nephrolithotomy  has  been  performed  primarily  and  there 
is  an  obstruction  of  the  ureter  to  be  overcome  at  a  second  operation,  drainage  should 
be  continued  until  the  symptoms  of  infection  and  inflammation  have  subsided. 


CHAPTER  XLIII. 

THE  SURGERY  OF  THE  URETER. 
By  Howard  A.  Kelly,  M.D. 

The  surgery  of  the  ureters  is  a  growth  of  the  past  two  decades.  Prior  to  that 
period,  the  one  commonly  recognized  ureteral  malady  was  a  fistula  opening  into 
the  yagina,  and  the  only  sure  plan  of  treatment  was  a  nephrectomy.  Today, 
thanks  to  the  labors  of  a  galaxy  of  contemporary  surgeons,  the  surgery  of  the 
ureters  stands  on  a  plane  which  for  completeness  of  conception  and  technic  can  be 
compared  fayorably  with  the  surgery  of  any  other  individual  organ  in  the  body. 

The  reason  for  the  remarkable  growth  of  this  delicate  branch  of  the  surgical 
tree  lies  not  so  much  in  a  minuter  exploration,  nor  in  the  discovery  of  new  pathologic 
affections  of  the  organ,  as  in  the  fact  that  the  conditions  which  oftenest  call  for 
relief  are  those  which  have  been  created  by  the  hands  of  the  surgeon  himself.  In 
other  words,  as  abdominal  surgeons  have  become  more  and  more  active  and  aggres- 
sive, injuries  of  the  ureters  have  followed  'pari  passu. 

AYith  the  first  advances  in  abdominal  surgery,  within  the  last  two  decades, — 
and  by  advances  I  mean  not  so  much  the  invention  of  new  operations  a,s  the  entrance 
upon  the  field  of  an  army  of  new  men,  in  our  cities,  in  small  towns,  and  in  rural 
districts, — with  the  advent,  as  I  say,  of  this  fresh  impulse,  there  was  an  immediate 
and  enormous  increase  in  the  percentage  frequency  of  ureteral  injuries  and  sequelae. 
The  flood  of  inexperience  is  passing  over,  however,  and  I  am  thankful  to  note  that 
ureteral  injuries  are  becoming  more  rare. 

The  ureteral  diseases  which  call  for  surgical  interference  may  be  divided  accord- 
ing to  causation  into  two  groups:  the  surgical  and  the  non-surgical. 

The  surgical  group  includes  all  those  injuries  which  arise  at  the  hands  of  the 
surgeon  in  the  course  of  an  abdominal  or  of  a  pelvic  operation.  Lesions  of  this 
sort  are  almost  exclusively  confined  to  the  pelvic  portion  of  the  ureter  where  it 
lies  in  close  contact  with  the  genital  organs  which  so  frequently  call  for  radical 
operations,  in  a  part  of  the  abdomen  where  the  ureter  is  less  readily  traced  and 
exposed  to  view,  and  so  less  readily  protected  from  such  accidental  injuries. 

Inasmuch  as  pelvic  operations  are  most  commonly  done  upon  women,  it  is 
evident  that  the  group  of  ureteral  affections  referred  to  must  also  be  found,  in  an 
overwhelming  majority  of  instances,  in  women  too. 

The  surgical  lesions  of  the  ureter  are:  A  cut  opening  the  lumen  of  the  ureter, 
without,  however,  completely  severing  it;  complete  division  of  the  canal;  ligation 
of  the  ureter;  exsection  by  tearing  or  by  division,  in  the  process  of  removing  an 
organ,  or  a  segment  of  the  pelvic  portion  of  the  ureter;   injury  to  the  blood-supply 

732 


LESIONS    OF    THE    URETER.  733 

of  the  ureter,  entailing  a  subsequent  sloughing,  kinking,  or  compression  of  the 
ureter  by  the  traction  of  sutures  or  the  pressure  of  dressings. 

The  group  of  ailments  which  are  not  surgical  in  their  origin  are:  Congenital 
fistula;  fistulse  from  injury  during  labor;  strictures;  tuberculosis;  pyoureter; 
calculus;  malignant  disease. 

The  causes  of  the  various  surgical  lesions  of  the  ureter,  as  stated,  He  pri- 
marily at  the  door  of  the  surgeon.  Such  injuries  are  far  more  apt  to  occur  in  the 
hands  of  a  neophyte  than  in  the  hands  of  an  experienced  surgeon.  The  manifest 
lesson  to  be  drawn  from  this  fact  is  a  more  thorough  knowledge  of  anatomy, 
and  a  greater  watchfulness  in  the  course  of  the  operation  over  all  its  details.  Not 
all  lesions,  however,  are  to  be  charged  up  to  inexperience;  in  some  myomata,  in 
bad  inflammatory  cases,  and  in  cases  of  old  extrauterine  pregnancies,  as  well  as  in 
some  badly  adherent  ovarian  tumors,  the  ureter  sticks  tight  to  the  afl^ected  organ, 
and  as  the  latter  is  pulled  up  from  the  pelvic  floor,  in  the  process  of  enucleation, 
the  ureter  is  brought  out  with  it  and  sacrificed  unwittingly. 

Perhaps  the  commonest  of  all  surgical  lesions  is  that  due  to  operations  for  cancer 
of  the  cervix.  In  the  older  operations,  especially  vaginal,  when  clamps  were  em- 
ployed, the  injury  was  often  direct.  In  the  more  radical  operations  which  we  now 
employ  the  extensive  separation  of  the  ureter  from  the  cancer,  frequently  required, 
may  lead  to  an  interference  with  the  blood-supply  of  the  ureter;  and  from  this 
results  necrosis  and  a  fistula. 

Calculi  pass  down  from  the  pelvis  of  the  kidney  and  lodge  either  just  below 
the  starting-point  high  up  in  the  loin,  or  stick  just  above  the  pelvic  brim,  or,  finally, 
on  the  pelvic  floor,  usually  but  a  short  distance  from  the  vesical  end  of  the  ureter. 

A  tuberculosis  of  a  ureter  is  always  secondary  to  a  renal  affection.  A  pyoureter 
depends  upon  and  is  secondary  to  a  stricture,  while  a  stricture  is,  with  a  few  ex- 
ceptions, produced  by  a  stone  or  a  tuberculosis. 

Primary  malignant  disease  of  the  ureter  is  exceedingly  rare;  secondary  involve- 
ments take  place  from  the  kidney  above  or  from  the  cervix  uteri  below  (see  Fig. 
839). 

A  diagnosis  of  any  of  these  various  ureteral  affections  is  made  by  noting: 
(1)  The  side  in  which  the  pain  is  felt;  (2)  the  point  of  escape  of  the  urine,  in  the 
case  of  a  fistula;  (3)  the  character  of  the  discharge;  (4)  by  making  a  careful 
cystoscopic  examination  of  both  ureteral  orifices  associated  with  a  sounding;  and 
(5)  a  catheterization  of  each  ureter. 

It  is  easy  to  distinguish  a  ureteral  from  a  vesical  fistula  by  making  an  injection 
of  a  colored  fluid  (aniline)  into  the  bladder,  which  will  escape  from  a  vesical  and 
not  from  a  ureteral  fistula. 

When  there  is  a  stone  lodged  in  the  ureter,  there  is  usually  a  well-defined  loca- 
lized pain,  and  if  the  stone  is  low  down  in  the  pelvic  portion,  it  can  often  be  felt  by 
vaginal  or  by  rectal  palpation. 

Both  stone  and  tuberculosis  are  marked  by  pain  and  pus,  and  often  by  blood 
in  the  urine. 


734 


THE  SURGERY  OF  THE  URETER. 


Fig.  823.  —  Typical 
Scratches  on  a 
Waxed  Cathe- 
ter. 


A  tubercular  ureter  feels  like  a  thick  nodular  cord  through  the  anterior  vaginal 
wall  and  vault;  this  is  always  evidence  of  disease  of  long  stand- 
ing in  the  kidney  above,  and  in  the  bladder  below. 

The  present  status  of  tuberculosis  of  the  ureter  is  that  it  is 
always  descending,  and  never  ascending.  The  disease  follows 
the  excretory  current.  In  the  male  there  are  two  currents  in 
the  genito-urinary  apparatus,  both  making  for  the  bladder — 
one  from  the  kidney  downward,  and  the  other  from  the  epi- 
didymis or  the  seminal  vesicles  upward. 

Injuries  to  the  Ureter. — If  a  ureteral  affection  cannot  be 
felt  by  the  finger  introduced  into  the  vagina  or  into  the  rectum, 
then  there  is  only  one  other  direct  way  of  discovering  the  dis- 
ease without  making  an  incision,  and  that  is  by  a  cystoscopic 
examination,  associated  with  a  catheterization  of  the  diseased 
ureter.  This  direct  visual  procedure  is  of  all  methods  the  most 
satisfactory,  because  the  most  positive  and  convincing.  In  the  first  place,  if  there 
is  an  inflammatory  disease,  such  as  a  tuberculosis  on  the  affected  side,  the  orifice 
of  the  ureter  of  that  side 
appears  edematous,  or  much 
reddened,  or  ulcerated.  Some- 
times it  appears  as  a  little 
pocket,  and  is  displaced  to- 
ward the  posterior  lateral  part 
of  the  bladder.  On  introduc- 
ing a  catheter  into  the  ureter, 
a  stricture  is  recognized  either 
as  an  obstruction  or  as  a  nar- 
rowing, through  which  the 
catheter  is  forced  with  diffi- 
culty. Once  beyond  the  stric- 
ture, the  pent-up  fluids  force 
their  way  down  the  catheter 
and  are  discharged  until  the 
ureter  and  the  distended  pelvis 
of  the  kidney  are  emptied.  A 
considerable  accumulation  of 
watery  urine,  or  turbid  urine, 
or  pus  may  be  let  out  in  this 
way.  If  there  is  a  stone  in 
the  ureter,  a  little  coating  of 
wax  on  the  end  of  the  catheter 
will  show  the  presence  of  the 

Fig.  824. — Examining  the  Scratched  Waxed  End  of  the  Ure- 
Stone  by  the  gouges  or  scratch  teral  catheter  by  Reflected  Light. 


EARLY  TREATMENT   OF   DISEASES    OF   THE    URETER. 


735 


-% 


marks  (see  Fig.  823)  seen  on  the  surface  when  looked  at  with  a  low-power  lens 
after  withdrawal  (see  Fig.  824).     Fig.  825  shows  a  ureteral 
calculus  causing  the  scratch  marks  seen  in  Fig.  823. 

If  there  is  a  fistula  of  the  ureter,  a  catheter  introduced 
on  the  same  side  as  the  fistula  draws  no  urine  and  meets 
an  obstruction,  as  a  rule,  a  short  distance  from  the  ureteral 
orifice,  at  the  ureteral  end  of  the  fistula. 

All  these  direct  observations  of  the  affected  ureter  are 
associated  with  similar  observations  of  the  opposite  side, 
which  may  be  seen  to  be  discharging  its  urine  normally, 
at  intervals  of  a  few  seconds,  in  clear  jets.  It  is  best,  as  a 
rule,  to  avoid  catheterizing  a  sound  ureter,  if  there  is  much 
disease  in  the  bladder.  Enough  urine  for  careful  bacteriologic  and  microscopic 
examination  can  be  caught  in  the  speculum  without  introducing  a  catheter. 

Early  Treatment  of  Dis- 


Fig.  825. — Ureteral  Cal- 
culus Lodged  Above 
THE  Vesical  Orifice 
Giving  Scratch  Marks. 


Fig.  826. — Anastomo- 
sis Bougie  for 
Joining  Ends  of 
Ureter. 


o    o     O 


eases  of  the  Ureter. — Treat- 
ment of  a  surgically  injured 
ureter  difl^ers  according  as  the 
injury  is  recent,  that  is  to  say, 
just  made  and  discovered  in  the  course  of  an  operation,  or 
inflicted  some  time  before  and  causing  a  fistula  of  weeks  or 
months. standing.  Sometimes  the  kidney  of  the  side  involved 
is  extensively  diseased,  owing  to  the  distention  of  the  ureter  by 
the  pressure  of  a  pelvic  tumor  and  a  subsequent  infection.  In 
an  instance  of  this  kind,  if  the  patient's  condition  will  permit 
it,  and  the  opposite  kidney  is  known  to  be  sound,  it  is  best  to 
take  out  the  kidney  at  once.  If  the  patient  is  too  ill  for  such 
a  radical  operation,  then  the  diseased  ureter  should  be  brought 
to  the  surface  of  the  body,  sewn  into  the  angle  of  the  incision, 
and  after  the  patient  has  recovered,  if  there  is  any  continued 
discharge  from  the  fistula,  the  kidney  should  be  taken  out. 
Where  the  injury  to  the  ureter  is  an  extensive  one,  so  that  it 
cannot  be  anastomosed  either  to  the  bladder  or  to  the  lower 
end  of  the  ureter,  if  the  opposite  kidney  is  sound,  the  best  plan, 
in  a  non-infected  case,  is  either  to  ligate  the  ureter  and  drop 
it,  or  to  take  out  the  kidney.  A  ligature  must  be  tied  tight, 
and  it  is  best  to  insert  a  small  provisional  drain  in  case  of  a 
leakage.  If  the  ureter  has  been  divided,  or  a  small  portion 
only  has  been  sacrificed,  the  best  plan  then  is  to  tie  the  lower 
end,  and  to  anastomose  the  upper  end  into  the  lower  below  the 
ligature,  by  means  of  the  instrument  shown  in  Fig.  826,  through 
a  slit  in  the  side  of  the  lower  end,  as  shown  in  Fig.  832.  An 
end-to-end  anastomosis  of  the  ureter  may  be  done  under  the 


736 


THE  SURGERY  OF  THE  URETER. 


most  favorable  circumstances,  as  when  the  ureteral  walls  are  thick  enough  for 
a  thorough  suturing  without  penetrating  the  mucosa,  and  when  they  can  be 
brought  snugly  together  without  any  tension.     If  the  ureter  is  injured  low  down 


Fig.  827. — Anastomosis  of  Ureteral  Ends  after  Di\  isiox   ox  (Slide. 

After  reraoval  of  the  iastrument  the  Uttle  longitudinal  incision,  through  which  it  was  introduced,  is  also  sutured. 

Bj'  rotation  of  the  ureter  by  traction  on  the  sutures,  the  posterior  part  is  exposed  as  well. 


in  the  pelvis,  the  best  plan  then  is  to  make  a  little  opening  in  the  posterior  wall 

of  the  bladder,  near  the  side  of  the  pelvis,  and  to  anastomose  the  ureter  into  the 

bladder  retroperitoneally,  as  shown  in  Figs.  828,  829,  830,  and  831.     In  all  these 

anastomotic  openings  it  is  best  to  employ  fine  silk  (catgut  is  also  admissible)  and 

to  avoid  any  part  of  the  suture  appearing  on 

a  mucous  surface,  where  it  can  be  brought  into 

contact  with  the  urine.     It  is  also  best  in  all 

these  operations  to  avoid,  so  far  as  possible, 

any  extensive  denudation  or    detachment    or 

rough    handling   of    the    ureter    itself.      The 

ureter  cannot  be   lifted    completely  out  of   its 

bed  for  a    stretch  of    several    inches   without 

great  risk  of  its  sloughing. 

In  every  instance,  also,  the  ureter  should 
be  covered  by  peritoneum  and  kept  as  far 
away  as  possible  from  any  areas  to  be  closed 
by  granulation.  A  little  drain  down  to  the 
point  of  anastomosis  constitutes  a  temporary 
safeguard,  for  which  the  operator  vsill  some- 
times be  thankful.  If  there  is  no  escape  of  urine,  the  drain  can  be  slipped  out  in 
four  or  five  days. 

Late  Operations  for  Surgical  Injury  of  the  Ureter. — In  a  late  operation 


Fig.  828. — A  Method  of  Turning  the 
Ureter  into  the  Bladder  (G.  Hunner). 


LATE    OPERATIONS    FOR    SURGICAL    INJURY    OF   THE    URETER. 


737 


for  a  surgical  injury  of  the  ureter  one  has  always  to  do  with  a  fistula,  and  the  first 
question  of  importance  coming  up  for  solution  is  this: 

Is  the  function  of  the  kidney  on  the  fistulous  side  materially  impaired  ? 

How  much  urea  per  diem  is  excreted  through  the  fistulous  ureter  ? 

Is  there  any  infection  of  the  fistulous  side  ? 

Is  the  opposite  kidney  capable  of  doing  all  the  work,  and  of  maintaining  life  ? 


Fig.  829. — Showing  a  Working  Incision  into  the  Vertex  of  thk  Bladuik,  Used  to  Draw  the  Ureter 
Through  the  Little  Opening  Made  in  the  Bladder  at  the  Nearest  Point,  Securing  an  Extraperi- 
toneal Implantation. 


The  operator  will  determine  upon  his  course  according  to  the  answers  given 
to  these  questions.  The  operation  for  an  old  fistula  of  the  uretei-,  though  often 
successful,  is  by  no  means  simple.  It  may  in  any  given  case  unexpectedly  prove 
one  of  the  most  delicate  and  difficult  pieces  of  surgery  the  surgeon  can  be  called 
upon  to  perform.  The  ureter  may  be  cut  off  at  some  distance  from  the  bladder 
and  the  fistulous  orifice  may  itself  lie  at  some  little  distance  from  the  ureter 
VOL.  II — 47 


738 


THE  SURGERY  OF  THE  URETER. 


proper.  The  operator,  on  cutting  down  to  the  ureter,  may  find  it  so  buried  in  scar 
tissue  as  to  necessitate  the  sacrifice  of  a  considerable  portion  of  the  ureter  in  order 
to  reach  the  healthy  part  capable  of  anastomosis,  and  having  reached  this  part, 
he  may  then  find  it  impossible  to  carry  it  across  the  distance  lying  between  the  ureter 
and  the  bladder.  He  must,  for  tliis  reason,  be  well  posted  as  to  the  safety  of  re- 
moving the  fistulous  kidney  in  the  case  of  necessity. 

What  to  do  for  Ureteral  Fis- 
tulas.— In  investigating  the  discharge 
from  a  ureteral  fistula,  it  is  not  safe 
to  run  a  ureteral  catheter  up  into  the 
ureter,  as  this  may  cause  a  serious 
ascending  infection.  The  better  plan 
is  to  put  the  patient  on  a  bed-pan  and 
collect  the  discharge  as  it  runs  out  for 
several  hours,  and  then  to  examine 
this  for  urea.  If  the  urea  is  very  low, 
and,  above  all,  if  there  is  an  infection, 
it  would  be  wiser  to  take  out  the  kid- 
ney than  to  attempt  an  anastomosis, 
which  is  most  likely  to  fail  under  such 
conditions.  Where  the  fistula  opens 
at  the  vault  of  the  vagina,  it  is  some- 
times a  sore  temptation  to  the  plastic 
surgeon  to  turn  the  ureter  into  the 
bladder  by  one  of  the  various  methods 
devised.  This  operation,  however,  is 
more  attractive  on  paper  than  in  the 
actual  performance,  as  it  is  difficult 
and  liable  to  fail.  The  writer  suc- 
ceeded in  one  case,  where  there  was  a 
ureteral  fistula  at  the  vaginal  vault 
involving  both  ureters,  in  cutting  open 
the  bladder  at  a  point  close  to  the 
ureters  and  sewing  the  lower  lip  of  the 
cut  bladder  to  a  denuded  strip  extend- 
ing across  the  vagina  behind  the  ureters,  in  this  way  turning  a  little  area  of  the 
vaginal  vault  with  the  ureteral  fistulse  into  the  bladder.  This  operation  was 
perfectly  successful,  but  it  is  difficult  and  not  likely  to  succeed  as  a  routine 
procedure.  The  anastomosis  of  an  old  fistula  ought  to  be  made,  as  a  rule,  above 
the  symphysis  through  a  lateral  incision,  through  the  linea  semilunaris,  extraperito- 
neally.  Such  an  incision  should  be  made  low  down  and  the  peritoneum  turned 
back  from  the  iliac  vessels  and  the  pelvic  wall  until  the  ureter  is  found.  The  ureter 
should  then  be  detached  with  great  care  from  its  surroundings  and  cut  loose  from 


Fig.  830. — Retropehitoneal  Anastomosis  of  Short- 
ened Ureter  into  Bladder. 
Figure  shows  traction  suture  introduced  through 
urethra,  in  order  to  pull  ureter  through  little  opening 
near  dorsum  of  bladder.  Note  obliquity  of  ureteral 
orifice. 


CALCULUS    OF   THE    URETER. 


739 


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Fig.  831. — Lateral   View    of    k    Tr.anspl.'\.nted 

Ureter  (G.  Hunner). 

The  new  ureter  occupies  the  position  of  the  dotted 

line,  and  passes  above  the  uterine  vessels. 


the  fistulous  opening  in  a  healthy  part  of  the  organ,  after  which  the  bladder  is 
drawn  to  the  ureter  and  the  anastomosis  effected  through  a  little  slit  in  the  lateral 
vesical  wall.  Years  ago  I  devised  the 
plan  of  loosening  the  bladder  from  its 
surroundings,  and  pulling  it  back  in  the 
pelvis,  to  meet  a  short  ureter,  in  this  way 
effecting  an  anastomosis  without  tension, 
which  otherwise  would  have  been  impos- 
sible. If  the  peritoneum  is  torn  in  free- 
ing the  ureter,  it  will  be  best  to  put  in  a 
drain  for  a  time;  and  a  drainage  open- 
ing at  the  vaginal  vault  is  preferable  to 
one  upon  the  abdomen. 

Congenital  Fistula. — In  a  congenital 
fistula  the  ureter  opens  into  the  urethra, 
or  into  the  vestibule,  or  at  a  point  below 

its  normal  orifice  of  discharge  into  the  bladder.     In  such  cases,  if  the  ureter  is 
distended  above,  an  incision  into  the  enlarged  ureter  may  be  made  through  the 

bladder  wall,  preferably  with  a 
thermocautery,  in  this  way  short- 
circuiting  the  fistula. 

Calculus  of  the  Ureter. — In 
calculus  of  the  ureter,  after  deter- 
mining the  presence  of  a  stone,  and 
the  condition  of  the  kidney  on  that 
side,  the  operator  is  chiefly  con- 
cerned to  know  just  where  the  cal- 
culus is  situated.  This  will  be  de- 
termined by  noting  the  point  of 
obstruction  with  the  ureteral  cath- 
eter, as  impeding  the  progress  of 
the  catheter,  as  well  as  by  noting 
the  exact  point  at  which  the  cath- 
eter on  withdrawal  is  felt  to  be 
liberated  from  the  grasp  of  the 
calculus,  pinching  it  against  the 
ureteral  wall.  An  .r-ray  picture 
also  gives  precise  information  as  to 
the  location  of  the  stone. 

Inasmuch  as  the  course  of  the 

ureter  is  a  long  one  from  the  pelvis 

of   the   kidney  to  the  neck   of   the 

bladder,  an  incision  for  the  removal  of  a  stone  may  be  made  at  a  point  from  the 

loin  posteriorly  to  the  vagina  below. 


Fig.  832. — Weller  Van  Hook's  Method  of  End-to-side 
Anastomosis  of  the  Upper  End  of  the  Ureter  into 
THE  Lower. 

In  the  upper  figure  the  distal  portion  is  tied  and  slit, 
while  the  upper  end  is  being  drawn  into  the  slit  by  the  tem- 
porary suture,  a.  The  lower  part  of  the  figure  shows  the 
anastomosis  completed  by  the  suture  of  the  entering  por- 
tion to  the  margins  of  the  slit,  the  traction  suture  being 
withdrawn. 


740 


THE   SURGERY    OF   THE   URETER. 


Fig.  833. — Preliminary  Fine  Silk  Sutures  Passed  through  the  Outer  Walls  of  the  Ureter  Before 

Incising  and  Removing  the  Stone. 
In  making  the  incision  to  remove  the  stone,  the  sutures  must  be  pulled  widely  apart. 


Fig.  834. — A  Stricturbd  Ureteral  Orifice  with  a  Stone  Lodged  above  it. 
The  metal  dilator,  2.5  mm.  in  diameter,  is  seen  introduced  as  far  as  the  stone.     This  was  followed  by  dilators  to 

the  size  of  5  mm. 


CALCULUS    OF   THE    URETER. 


741 


If  the  stone  is  up  near  the  kidney,  a  posterior  incision  is  made  as  in  suspension 
of  the  kidney,  when  the  kidney  is  rotated  by  pulling  on  its  fatty  capsule  with  a  num- 
ber of  forceps  until  the  ureter  is  brought  into  the  field  of  operation.  A  delicate 
longitudinal  incision  is  made  over  the  stone,  avoiding  the  vessels,  when  the  stone 
is  carefully  lifted  out,  taking  care  not  to  tear  the  wall  of  the  ureter,  after  which 
the  incision  is  closed  with  delicate  silk  sutures,  slightly  infolding  the  ureteral  wall 
(see  Fig.  833).  If  the  stone  is  lodged  above  the  brim  of  the  pelvis,  the  incision  made 
may  be  like  that  for  the  removal  of  the  appendix,  avoiding,  however,  the  opening 
of  the  peritoneum.  Upon  reflecting  the  peritoneum  with  the  colon  and  cecum, 
the  ureter  is  exposed,  adhering  to  the  peritoneum,  and  the  stone  is  readily  located 
by  touch,  and  then  exposed  and  excised  by  a  longitudinal  incision  long  enough 


2.5  3.5  h:  4t.5  5 

Fig.  835. — Ureteral  Dilators  from  Size  2.5  to  5  mm. 


to  take  it  out  easily,  without  tearing  the  ureter.  When  the  ureter  is  dilated,  as  it 
often  is  above  a  stone  which  has  long  been  embedded  on  the  pelvic  floor,  it  is  some- 
times easier  to  get  at  the  stone  by  pushing  up  the  dilated  ureter  to  a  more  conve- 
nient and  accessible  point  above  the  brim  (Israel),  when  it  is  removed  and  the  wound 
sutured  as  usual. 

A  stone  in  the  extreme  lower  part  of  the  ureter,  just  behind  the  bladder  or 
juxtavesical,  which  cannot  readily  be  thrust  upward,  may  be  removed  by  a  lateral 
incision  in  the  linea  semilunaris,  separating  the  peritoneum  from  the  pehdc  wall, 
until  the  ureter  and  the  stone  are  felt.  These  cases  are  sometimes  difficult,  owing 
to  the  depth  of  the  pelvis  and  the  inaccessibility  of  the  stone.  I  have  had  a  case 
in  which  a  stone  lodged  in  the  lower  end  of  the  ureter  (see  Fig.  834)  was  induced 


742 


THE  SURGERY  OF  THE  URETER. 


to  escape  without  a  cutting  operation  by  dilating  the  narrow  ureteral  orifice  with 
hollow  bougies  (see  Fig.  835)  up  to  the  size  of  5  mm.  in  diameter.  In  women 
the  most  satisfactory  avenue  for  the  removal  of  a  ureteral  stone,  when  it  can  be 
reached  by  the  vagina,  is  through  an  incision  in  the  vaginal  wall  directly  over  the 
stone.  The  ureter  is  thus  exposed  and  incised  longitudinally,  the  stone  removed, 
and  if  the  case  is  an  aseptic  one,  the  wound  may  be  closed.  It  is  best  in  such  cases, 
if  there  is  any  doubt  about  the  suturing  of  the  ureter,  to  leave  in  a  drain,  not  attempt- 
ing to  close  the  vagina  entirely.  Even  if  a  fistula  is  formed,  it  is  sure  to  get  well  of 
itself  in  a  few  weeks'  time.  When  the  stone  can  be  seen  by  the  cystoscope,  pro- 
jecting into  the  bladder  (see  Fig.  836),  or  when  the  stone  is  so  far  down  as  to  cause 


Fig.  836. — Calculi  Lodged  in  the  Vesical  End  of  the  Ureter  and  Projecting  into  the  Bladder. 


a  bulging  of  the  vesical  mucosa  into  the  lumen  of  the  bladder  (see  Fig.  837),  a 
good  way,  in  women,  is  to  open  the  air-distended  bladder  in  the  knee-breast  pos- 
ture, to  retract  the  margins  of  the  incision,  exposing  the  hard  bulging  tumor,  and 
then,  by  means  of  a  simple  incision  with  alligator  scissors,  to  lay  bare  and  remove 
the  stone.  If  there  is  any  doubt  as  to  whether  all  stones  have  been  removed,  it 
will  be  a  wise  plan  not  to  close  the  vaginal  incision,  but  to  leave  it  to  close  sponta- 
neously. 

A  valuable  method  for  locating  the  position  of  the  stone  is  to  catheterize  both 
ureters,  as  shown  in  the  diagram  (see  Fig.  838).  The  right  catheter  has  entered 
the  full  length  of  the  ureter  and  the  renal  pelvis,  while  the  left  catheter  stops  short 
at  a  supposed  stricture  or  stone.     The  catheters  are  then  grasped  as  one  at  the  vul- 


TUBERCULOSIS    OF   THE    URETER. 


743 


var  orifice  and  drawn  out  together.  The  difference  in  distance  between  the  tips  of 
the  catheters  measures  the  difference  between  the  top  of  the  pelvis  of  the  kidney 
and  the  site  of  the  obstruction. 

A  stricture  of  the  ureter  is  usually  associated  with  some  other  disease,  such  as 
tuberculosis  or  calculus,  when  it  does  not  call  for  treatment  jper  se.  However,  a 
stricture  is  sometimes  found  at  the  vesical  orifice,  due  to  a  localized  catarrhal 
condition  within  the  bladder.     Such  an  interesting  affection  is  associated  with  a 


Fig.  837. — Liberation  of  a  Calculus  Bulging  Out  into  the  Bladder  by  Incising  the  Vesicofistular 
Septum  in  the  Knee-breast  Position,  and  Then  Incising  the  Thinned-out  Vesical  Mucosa  and  the 
Ureteral  Wall. 


distention  of  the  ureter  and  a  curious  pouting  or  bulging  of  the  ureter  into  the  lumen 
of  the  bladder.  When  such  a  condition  is  recognized  cystoscopically,  the  only 
treatment  necessary  is  to  slit  the  bag  in  a  moment  of  extreme  distention,  thus 
effecting  a  wide  opening  into  the  bladder,  which  nature  will  maintain. 

Tuberculosis  of  the  Ureter.— A  ureter  which  is  greatly  thickened  with  tuber- 
culosis ought  always  to  be  removed,  either  at  the  time  of  removal  of  the  diseased 
kidney  or  as  a  secondary  step  after  the  patient  has  recovered.  Patients  who  carry 
large,  thick,  tubercular  ureters  rarely,  if  ever,  make  a  good,  complete  recovery, 


744 


THE  SURGERY  OF  THE  URETER. 


but  suffer  more  or  less  from  dysuria  and  the  constant  infection  of  the  bladder. 
While  this  is  true,  it  is  also  true  on  the  other  hand  that  a  ureter  which  appears  a 
little  thickened  or  somewhat  cord-like,  and  which  an  operator  without  great  exper- 
ience is  apt  to  mistake  for  a  tubercular  ureter,  is  best  let  alone.  The  cord-like 
condition  of  the  ureter  is  not  often  due  to  a  tubercular  infiltration.     Ureterectomy 


Fig.  838. — Shows  the  Method  of  Estimating  the  Exact  Position  of  a  Ureteral  Obstruction. 
The  catheter  on  the  right  side  enters  its  full  length,  say  28  cm.,  while  that  on  the  left  stops  short  at  the 
obstruction  x,  say  18  cm.  short  of  the  top  of  the  renal   pelvis.     Upon  grasping  both  catheters  between   thumb 
and  forefinger  at  the  vulva,  and  withdrawing  them  simultaneously,  so  as  to  preserve  their  relative  positions  in 
the  body,  the  difference  in  the  level  between  the  top  of  the  renal  pelvis  and  the  obstruction  is  easily  estimated. 


is  less  frequently  done  now  than  ten  years  ago.  The  ideal  operation  for  removal 
of  the  ureter  is  a  nephro-ureterectomy,  in  which  kidney  and  ureter  are  removed 
in  one  piece,  without  contamination  of  the  contiguous  tissues.  It  is  best,  as  a  rule, 
to  release  the  kidney  first  by  a  suitable  posterior  or  lateral  incision,  and  then  to 
free  the  ureter  as  far  as  possible,  usually  as  far  as  the  pelvic  brim;  the  operator 


TUBERCULOSIS    OF   THE    URETER. 


745 


next  makes  an  incision  in  the  semilunar  line  over  the  true  pelvis  and  lays  bare  the 
ureter  at  the  brim  of  the  pelvis,  and  then  pushing  the  kidney  with  the  attached  ureter 
under  the  broad  bridge  of  abdominal  wall,  left  intact  between  the  incision  in  the 
loin  and  the  incision  in  front  in  the  lower  abdomen,  concludes  the  operation  by 
extirpating  the  pelvic  portion  of  the  ureter.  If  this  operation  is  done  gently  and 
carefully,  there  ought  to  be 
no  trouble  of  any  moment 
after  the  detachment  of  the 
kidney.  The  ureter  should 
be  ligated  at  its  vesical  origin, 
and  the  end  sterilized  and 
dropped.  Great  care  must  be 
taken  throughout  not  to  con- 
taminate the  wound  with  any 
infected  material  from  the 
kidney  or  ureter.  It  is  some- 
times best  to  tie  off  the  uterine 
vessels  in  order  to  expose  the 
lower  end  of  the  ureter.  In 
other  cases  the  anterior  por- 
tion of  the  ureter  can  be 
reached  by  enlarging  the  little 
hole,  through  which  it  passes 
under  the  broad  ligament, 
with  the  finger,  and  then  pull- 
ing the  ureter  back  until  the 
vesical  end  is  exposed.  This 
cannot  be  done  so  well  if  the 
lower  end  is  much  diseased. 
I  have  in  several  instances 
excised  portions  of  the  blad- 
der with  the  kidney  and  the 
ureter,  doing  a  nephro-uretero- 
cystectomy.  In  such  a  case 
the  bladder  must  be  sewed 
up  with  great  care  with  at 
least  one  layer  of  fine  silk  su- 
tures, and  a  drain  should  be 
dropped  down  to  the  bladder  wound,  to  act  as  a  safety-valve  for  five  or  six  days. 
Malignant  disease  of  the  ureter  very  rarely  calls  for  treatment  as  an  affec- 
tion by  itself.  It  is  nearly  always  secondary  to  malignant  disease  of  an  adjacent 
organ,  and  as  the  ureter  is  only  involved  in  the  later  stages  of  the  affection,  an 
operation  is  out  of  the  question. 


^ 


^ 


Fig.   839. 


A  Case  of  Carcino.ma  of  the  Cervix,  Obstructixg 

THE  Ureters. 

Showing  the  involvement  of  the  pelvis  of  the  ureter  in  the  one 

form  of  malignant  disease  which  is  common  to  it,  and  one  mode  of 

producing  death.     On  the  left  side  the  ureter  is  double  throughout. 


746  THE    SURGERY    OF   THE   URETER. 

LITERATURE. 

Baldy,  J.  M.:    "Surgical  Injuries  to  the  Ureters,"  Amer.  Gyn.  and  Obst.  Jour.,  1894,  vol.  v,  p. 

489. 
Bovee,  J.  W.:  " Uretero-ureteral  Anastomosis,"  Ann.  Surg.,  1897,  vol.  xxv,  p.  51. 
Davenport,  F.  H.:   "A  Case  of  Incontinence  of  Urine  Due  to  Malposition  of  the  Ureter,"  Trans. 

Amer.  Gyn.  Soc,  1890,  vol.  xv,  p.  343. 
Fenger,  C:  "Surgery  of  the  Ureter,"  Trans.  Amer.  Surg.  Assoc.  1894. 
Heller,  A.:    " Hydronephrose  der  einen  Nierenhalfte  bei  doppelten  Ureteren  und  Nierenbecken," 

Deut.  Arch.  f.  khn.  Med.,  1869,  vol.  v,  p.  267. 
Kelly,  H.  A.:  Operative  Gyn.,  1907,  vol.  i,  pp.  482-565. 
Kelly,  H.  A.:    "Uretero-ureteral  Anastomosis;    Uretero-ureterostomy,"  Ann.  Surg.,  1894,  vol. 

xix,  p.  70. 
Lane,  W.  A.:    "Calculus  Impacted  in  the  Ureter  for  Twenty  Years;    Removal;    Recovery," 

Lancet,  1890,  vol.  ii,  p.  967. 
Maxson,  W.  H.:  "A  Truant  Ureter,"  Med.  News,  1896,  vol.  Ixviii,  p.  323. 
Ramsay,  O.:    "A  Complete  Duplication  of  the  Left  Ureter  from  the  Kidney  to  the  Bladder," 

Johns  Hopk.  Hosp.  Bull.,  1896,  vol.  vii,  p.  201. 
Sampson,  J.  A.:    "Ligation  and  Clamping  the  Ureter  as  Complications  of  Surgical  Operations," 

Amer.  Med.,  1902,  vol.  iv,  p.  693. 
Simon,  G.:  "Chirurgie  der  Nieren,"  Erlangen,  1871. 
Weller  Van  Hook:    "The  Surgery  of  the  Ureters,"  Jour.  Amer.  Med.  Assoc,  1893,  vol.  xxi,  pp. 

911,  965. 
Wertheim,  E.:    "Ein  neuer  Beitrag  zur  Frage  der  Radikaloperationen  beim  Uteruskrebs,"  Arch. 

f.  Gyn.,  1901,  vol.  Ixv,  p.  1. 
Witzel,  O.:    "Extraperitoneale  Ureterocystotomie  mit  Schragkanalbildung,"  Centralbl.  f.  Gyn., 

1896,  vol.  XX,  p.  289. 


CHAPTER  XLIV. 

SURGERY  OF  THE  KIDNEY 
By  Charles  P.  Noble,  M.D.,  and  Brooke  M.  Anspach,  M.D. 

HISTORY. 

The  first  operations  ever  performed  on  the  kidney  most  Kkely  were  incisions 
into  the  paranephric  area  or  nephrotomies  undertaken  to  evacuate  a  collection 
of  pus.  In  1757  Hevin^  wrote:  "It  is  very  doubtful,  if  not  absolutely  improbable, 
that  cutting  into  the  kidney  had  ever  been  practised  without  operation  having 
been  determined  by  an  abscess  swelling,  or  by  a  fistula  due  to  renal  abscess,  which 
had  broken  and  discharged  in  the  lumbar  region." 

According  to  Henry  Morris,^  the  practicability  of  nephrectomy  was  repeatedly 
discussed  in  the  sixteenth,  seventeenth,  and  eighteenth  centuries  by  Camerarius, 
Rousset,  Shenck,  Ducledat,  Cousinot,  Riolan,  von  Hilden,  Lafitte,  Borden,  Hevin, 
and  Ledran.  Gerdy,  in  1829,  referred  to  the  subject  at  considerable  length. 
Physiologic  experiments  had  shown  as  early  as  1670  that  life  could  be  maintained 
after  removing  one  of  the  kidneys;  nevertheless  there  was  great  prejudice  against 
the  operation. 

Pilcher^  says  that  in  1840  Rayer,  in  his  "Maladies  des  Reins,"  t.  iii,  p.  240, 
"summed  up  the  wisdom  of  the  ages  as  to  the  removal  of  a  kidney  in  his  sentence: 
'It  would  be  folly  to  attempt  such  an  operation.'  The  accounts  of  the  cases  of  the 
free  archer  of  Bagnolet  and  of  Hobson  the  English  consul  at  Venice,  in  the  case 
of  each  of  whom  it  is  related  that  under  peculiar  circumstances  a  kidney  had  been 
cut  down  upon,  stones  extracted,  and  recovery  followed,  remained  as  curiosa 
chirurgica."  The  possibilities  in  the  line  of  further  operative  work  on  the  kidneys 
were  suggested  by  the  experience  of  surgeons  in  their  dealings  with  ovarian  tumors. 
A  number  of  nephrectomies  had  been  done  by  mistake.  Diseased  kidneys  had  been 
mistaken  for  tumors  of  another  nature  and  removed  by  operation.  In  1868  Peaslee, 
after  having  removed  a  supposedly  solid  ovarian  tumor,  found  that  it  was  an  en- 
larged kidney.  "  Although  peritonitis  carried  ofl^  the  patient  on  the  third  day,  it  was 
noticed  that  an  adequate  urinary  discharge  was  furnished  by  the  remaining  kidney 
up  to  the  time  of  death." 

The  first  intentional  nephrectomy  was  done  by  Gustav  Simon,  of  Heidelberg, 

'  H^vin:  "Researches,  Historical  and  Critical,  on  Nephrotomy  or  Cutting  into  the  Kidney," 
Mem.  de  I'Acad.  Roy.  de  Chirurgie,  T.  iii,  part  2,  Sec.  24. 

^  Morris,  Henry:     "On  the  Origin  and  Progress  of  Renal  Surgery,"  Phila.,  1898. 

'  Pilcher,  L.  S.:  "The  Development  of  the  Surgery  of  the  Kidney  with  Some  of  the  Lessons 
Connected  Therewith,"  Ann.  Surg.,  1900,  xxxi,  p.  100. 

747 


748  SURGERY   OF   THE   KIDNEY. 

on  August  2,  1869.  This  operation  was  deliberately  undertaken  after  the  case 
had  been  carefully  studied  and  after  nephrectomy  had  been  practised  on  animals. 
It  made  a  great  impression.  The  next  nephrectomy,  according  to  Morris,  was 
done  by  Gilmore  in  America,  December,  1870,  on  a  woman  five  months  pregnant. 
Pilcher  says  that  von  Bruns,  in  March,  1871,  was  the  first  of  Simon's  imitators. 
Simon's  second  operation  was  performed  in  August,  1871,  for  calculous  pyeHtis; 
the  patient  died  of  pyemia.  Brandt  in  1873,  Marvaud  in  1875,  Langenbuch  in 
1875,  and  Jessop  in  1877,  performed  successful  nephrectomies. 

Nephrotomy  had  been  suggested  three  months  before  Simon's  first  nephrectomy 
by  Sir  Thomas  Smith,  and  in  July  of  the  same  year  Anandale  and  Spencer  Wells 
advised  nephrotomy  for  renal  calculus.  Bryant  performed  the  operation  in  1870. 
In  the  same  year  Gunn  and  Durham  made  incisions  into  the  paranephric  area  and 
Lente  and  Barbour  did  actual  nephrotomies. 

In  1878  Martin  adopted  nephrectomy  for  painful  floating  kidney,  and  had 
four  successful  cases.  The  operation  of  nephrorrhaphy  was  substituted  for  Martin's 
radical  measure  by  Hahn  in  1881.  Le  Dentu,  in  1889,  gave  the  procedure  its  present 
name  of  nephropexy.     The  first  nephropexy  in  America  was  done  by  Weir  in  1882. 

Paoh,^  of  Perugia,  performed  resection  of  the  kidney  in  a  number  of  dogs,  cats, 
and  rabbits;  the  procedure  was  followed  by  perfect  recovery.  An  account  of  this 
work  was  published  in  1890.  Morris  reports  that  the  first  partial  excision  of  the 
kidney  in  the  human  was  by  Czerny  in  1887;  it  was  done  for  angiosarcoma  follow- 
ing injury. 

According  to  Fenger,^  the  most  notable  step  in  conservative  kidney  surgery 
was  made  by  Henry  Morris,  of  London,  who  on  February  11,  1880,  had  the  courage 
to  remove  an  oxalate  of  lime  stone  weighing  thirty-one  grains  from  an  undistended 
healthy  looking  kidney,  by  an  incision  through  the  renal  parenchyma.  Morris's 
operation  proved  that  it  was  possible  to  save  the  kidney  from  the  destructive  influ- 
ences of  a  stone  without  sacrificing  the  organ. 


ANATOMY  OF  THE  KIDNEY. 

Embryology. — The  first  indication  of  the  kidney  is  found  in  the  renal  duct, 
which  arises  in  the  fourth  week  of  fetal  life  as  a  small  epithelial  proliferation  from 
the  Wolffian  duct,  a  short  distance  above  its  entrance  into  the  cloaca.^ 

Position.— The  kidneys  lie  deep  in  the  loins,  along  the  last  dorsal  and  the 
first  three  lumbar  vertebrae.  The  right  kidney  is  from  one-third  to  three-fourths 
of  an  inch  lower  than  the  left,  presumably  because  of  the  position  of  the  Uver 
immediately  above.  The  right  kidney  extends  as  high  as  the  lower  border  of  the 
eleventh  rib;   the  left  kidney  as  high  as  the  upper  border  of  the  same  rib.     Their 

1  Paoli:  "Etude  experimentale  sur  la  resection  du  rein,"  Verh.  des  X  Internat.  Med.  Cong., 
Berlin,  1890,  Bd.  iii,  Abth.  vii,  S.  248. 

2  Fenger,  Christian:  "Diseases  of  the  Kidney  Amenable  to  Operative  Treatment,"  Clinical 
Review,  Nov.,  1899,  xi,  77-102. 

^Kuster,  E.:     "Die  Chiruvgie  der  Nieren,"  Lief.  52b,  Deutsche  Chirurgie,  Stuttgart,  1896. 


ANATOMY    OF   THE    KIDNEY.  749 

superior  and  their  inferior  limits  are  on  a  level  with  the  upper  borders  of  the  tips 
of  the  spines  of  the  twelfth  dorsal  and  the  third  lumbar  vertebrae  respectively. 
The  long  axes  of  the  organs  are  oblique,  in  consequence  of  which  the  upper  ends 
are  8.5  cm,,  while  the  lower  are  11  cm.,  distant  from  the  spinal  column.' 

Each  kidney  also  is  rotated  slightly  backward  on  its  long  axis,  so  that  the  plane 
of  the  inner  margin  is  anterior  to  the  plane  of  the  outer  margin.  The  posterior 
surfaces  of  the  kidneys  look  backward  and  inward  toward  the  spinal  column. 
The  upper  one-third  of  the  posterior  surface  is  in  relation  with  the  diaphragm,  and 
the  lower  two-thirds  is  in  relation  with  the  fascia  overlying  the  psoas  magnus  mus- 
cle and  with  "the  anterior  lamella  of  the  lumbar  fascia  covering  the  quadratus  lum- 
borum  muscle.  The  anterior  branch  of  the  hypogastric,  the  ilio-hypogastric,  and 
the  ilio-inguinal  nerves  pass  outward  behind  the  lower  half  of  the  kidney. 

Kidney  Capsule. — The  kidneys  are  retroperitoneal  and  are  invested  by  con- 
nective tissue  which  is  extraperitoneal  in  origin. 

The  fatty  capsule  is  developed  especially  on  the  posterior  aspect  of  the  kidney 
about  the  convex  border  and  the  lower  pole;  in  front  it  is  very  thin.  Beneath  the 
inferior  extremity  of  the  kidney  it  forms  quite  a  pad  or  bolster  for  the  organ,  and  is 
continuous  with  the  cellulo-fatty  tissue  of  the  false  pelvis.  The  fatty  capsule 
itself  is  confined  between  the  two  layers  of  what  is  known  as  the  perinephric  fascia, 
and  throughout  its  extent  there  are  fibrous  septa  which  pass  from  the  kidney  to 
these  layers.  The  anterior  and  the  posterior  layers  of  the  perinephric  fascia  unite 
above  and  to  the  outer  side,  but  not  below  and  to  the  inner  side. 

The  anterior  layer,  which  is  the  thinner,  is  closely  applied  to  the  posterior  sur- 
face of  the  peritoneum;  passing  over  the  anterior  surface  of  the  kidney  and  the 
structures  at  the  hilum,  it  unites  in  the  median  line  with  its  fellow  of  the  opposite 
side.  Above  the  suprarenal  gland  the  anterior  layer  fuses  with  the  posterior  layer 
and  is  firmly  united  to  the  diaphragm.  Below  the  kidney  it  becomes  attenuated 
and  merges  with  the  cellular  layer  of  the  pelvic  fascia. 

The  posterior  layer  is  attached  along  the  median  line  to  the  bodies  of  the  verte- 
brae and  the  intervertebral  discs;  it  passes  over  the  psoas  muscle  and  over  the  poste- 
rior layer  of  the  lumbar  fascia  covering  the  quadratus  lumborum;  after  joining 
the  anterior  layer  above  the  suprarenal  gland  and  along  the  upper  convex  border 
of  the  kidney,  it  merges  with  the  subperitoneal  fascia. 

This  arrangement  of  the  perinephric  fascia  and  the  fatty  capsule,  which  is  for 
the  purpose  of  supporting  the  kidney,  permitting  at  the  same  time  a  small  range  of 
mobility,  explains  the  tendency  of  the  organ  to  prolapse  downward  and  inward. 
Normally  the  peritoneum  moves  slightly  with  the  kidney,  but  the  kidney  also  moves 
slightly  with  its  perinephric  fascia  under  the  peritoneum.  The  fatty  capsule  in 
turn  is  mobile  within  the  perinephric  fascia  and  the  kidney  within  the  fatty  capsule. 
The  capsule  proper  of  the  kidney  is  a  thm  though  well-defined  fibrous  coat;  it 
enters  the  hilum  and  lines  a  part  of  the  sinus.^ 

'  Piersol,  Geo.  A.:     "Human  Anatomy,"  Phila.,  1907. 

^  Morris,  Henry:     "Surgical  Diseases  of  the  Kidney  and  Ureter,"  London,  1901. 


750  SURGERY    OF   THE    KIDNEY. 

Relations  of  the  Kidney. — Each  kidney  weighs  from  four  to  five  ounces 
(110  to  140  grams).  The  upper  part  of  the  right  kidney  is  in  relation  with  the 
liver  and  is  covered  with  peritoneum.  The  ascending  colon  crosses  the  kidney 
below  its  middle,  and  at  this  point  there  is  therefore  no  peritoneal  covering.  The 
lower  extremity  of  the  right  kidney  is  in  contact  with  the  jejunum  and  is  covered 
with  peritoneum;  the  mesial  margin  of  the  kidney  is  overlapped  by  the  descending 
duodenum  and  is  non-peritoneal. 

The  upper  anterior  surface  of  the  left  kidney  is  in  contact  with  the  stomach 
and  is  covered  with  peritoneum.  The  upper  external  margin  is  in  contact  with  the 
spleen  and  has  a  peritoneal  covering.  The  tail  of  the  pancreas  crosses  the  middle 
part,  which  is  non-peritoneal.  Below  and  to  the  outer  side,  the  kidney  is  in  relation 
with  the  mesocolon;  to  the  inner  side  it  is  in  contact  with  the  jejunum  and  is  covered 
with  peritoneum. 

Hilum  of  the  Kidney. — The  extremities  of  the  kidney  are  rounded,  the  upper 
extremity  being  thicker  and  broader  than  the  lower,  and  surmounted  by  the  supra- 
renal capsule.  The  external  margin  is  convex  in  outline  and  is  unattached.  The 
internal  margin  is  concave  and  is  connected  with  the  ureter,  blood-vessels, 
lymphatic-s,  and  nerves  of  the  kidney.  These  structures  enter  the  kidney  through  a 
longitudinal  fissure  or  slit  known  as  the  hilum,  which  opens  into  a  C-shaped  chamber 
called  the  sinus  of  the  kidney.  The  latter  is  largely  occupied  by  the  expanded 
upper  extremity  of  the  ureter,  which,  with  its  subdivisions  the  calyces,  is  spoken 
of  as  the  renal  pelvis. 

The  structures  which  pass  through  the  hilum  and  enter  the  sinus  of  the  kidney 
are,  from  before  backward,  branches  of  the  renal  vein,  branches  of  the  renal  artery, 
other  branches  of  the  renal  vein,  and  the  ureter.  The  renal  artery  is  derived  from 
the  abdominal  aorta,  and  is  very  large  in  proportion  to  the  size  of  the  organ  which 
it  supplies.^  The  renal  vein  empties  into  the  inferior  vena  cava.  The  renal  nerves 
are  derived  from  the  solar  plexus  and  the  lesser  splanchnic  nerves.  Their  branches 
accompany  the  blood-vessels.  The  renal  lymphatics  are:  superficial,  covering  the 
surface;  and  deep,  accompanying  the  blood-vessels.  They  empty  into  the  lum- 
bar glands. 

The  Relation  of  the  Vascular  Supply  of  the  Kidney  to  the  Kidney  Pelvis 
and  Calyces. — The  configuration  of  the  renal  pelvis  and  calyces,  and  the  distri- 
bution of  the  renal  artery  in  the  kidney  substance,  is  of  considerable  importance 
from  a  surgical  standpoint.  The  pelvis  of  the  kidney  may  consist  of  one  common 
sac  or  it  may  be  divided  into  two,  ea;ch  of  which  communicates  with  the  calyces  in 
its  respective  situation,  and  opens  separately  into  the  upper  end  of  the  ureter. 

Brodel,^  who  examined  a  series  of  seventy  kidneys,  finds  that  in  the  ideal  form 
there  are  eight  calyces,  all  of  which  communicate  with  the  common  kidney  pelvis, 
the  expanded  upper  extremity  of  the  ureter.     The  longitudinal  plane  of  the  pelvis 

'  Deaver,  John  B.:     "Surgical  Anatomy,"  Phila.,  1903. 

2  Brodel,  Max:  "The  Intrinsic  Blood  Vessels  of  the  Kidney  and  their  Significance  in  Neph- 
rotomy," Johns  Hopkins  Hosp.  Bull.,  1901,  vol.  xii,  No.  118,  p.  10. 


ANATOMY    OF   THE    KIDNEY.  751 

runs  obliquely  from  the  posterior  inner  margin  of  the  kidney  to  the  outer  one- 
third  of  its  anterior  surface. 

There  are  eight  calyces,  an  upper  and  a  lower  one,  and  six  between  them, 
arranged  in  two  rows,  one  anterior,  the  other  posterior.  Each  row  leaves  the 
longitudinal  plane  of  the  kidney  pelvis  at  about  the  same  angle,  the  anterior  calyces 
being  directed  toward  the  convex  anterior  region  of  the  kidney  and  the  posterior 
to  a  line  just  a  little  behind  the  lateral  convex  border. 

In  the  case  of  a  divided  pelvis  there  is  a  zone  of  cortical  substance  which  extends 
to  the  hilum  and  divides  the  upper  pelvis  from  the  lower.  The  lower  pelvis  receives, 
as  a  rule,  the  greater  number  of  calyces.  There  are  usually  more  than  eight  calyces 
in  a  kidney  with  a  divided  pelvis.  Such  a  kidney  often  preserves  its  fetal  lobula- 
tions and  has  an  abnormal  arterial  circulation.  The  division  between  the  indi- 
vidual sections  of  the  pelvis  is  generally  marked  on  the  surface  by  an  especially 
deep  groove,  and  it  may  appear  as  though  there  were  two  separate  kidneys,  one  on 
top  of  the  other. 

Frequendy,  according  to  Brodel,  they  are  really  separate  organs  so  far  as  their 
arterial  distribution  and  their  excretory  functions  are  concerned.  Separate  renal 
arteries  are  commonly  associated  with  fetal  lobulation  of  the  kidneys.  Organs 
having  a  lobulated  form  usually  exhibit  a  long  hilum,  with  separate  arteries  and 
an  abnormal  renal  pelvis.  The  veins,  as  a  rule,  however,  collect  in  one  single 
trunk.^ 

The  renal  artery  divides  at  the  hilum  of  the  kidney  into  four  or  five  branches. 
Most  of  them  (three-fourths,  as  a  rule)  run  anteriorly  to  the  pelvis.  The  branches 
of  the  anterior  never  cross  over  to  the  posterior  division  or  vice  versa.  They  do  not 
anastomose  with  each  other,  being  end-arteries  in  the  strictest  sense  of  the  word. 
The  plane  of  division  between  the  two  arterial  trees  corresponds  to  the  plane  of  the 
axes  of  the  posterior  row  of  calyces.  It  may  be  spoken  of  as  the  bloodless  area  of 
the  kidney  and  is  the  plane  of  election  for  nephrotomy  incisions. 

The  most  vascular  plane  of  the  kidney,  and  the  line  of  incision  to  be  avoided 
in  nephrotomy,  passes  through  the  columns  of  Bertini.  The  latter  consist  of 
cortical  kidney  tissue  which  dips  down  between  the  anterior  and  the  posterior  row  of 
pyramids. 

The  position  of  these  planes  may  be  determined  by  the  surface  markings  of  the 
kidney. 

The  anterior  surface  of  the  normal  kidney  is  convex;  the  posterior  surface  is 
somewhat  flattened.  Near  the  outer  convex  border  and  on  the  anterior  surface 
there  is  a  longitudinal  furrow,  which  indicates  the  position  of  the  columns  of 
Bertini. 

The  plane  of  the  avascular  area  is  posterior  to  the  columns  of  Bertini.  It  passes 
from  a  longitudinal  line  slightly  behind  the  extreme  outer  convex  border  of  the 
kidney  through  the  center  of  the  hilum  and  nearly  parallel  to  the  posterior  surface 
(Fig.  840).     An  additional  advantage  of  such  a  section  of  the  kidney  is  found  in 

'  The  reader  is  referred  to  Brodel's  paper  for  a  detailed  description  of  the  kidney  veins. 


752 


SURGERY    OF   THE   KIDNEY. 


the  direct  opening  of  the  posterior  calyces  and  the  free  exposure  of  the  mouths  of 
the  anterior  calyces,  which  it  secures. 

The  columns  of  Bertini  are  indicated  in  lobulated  kidneys  by  a  distinct  furrow 


A^' 


nt.  pyramid 
with  double 


(<■  '/    TerforSiting 

capsular  bv. 


J  ^^ 

UTf-        Ant. view  of  left  Kidney 


jsterior  calyjc 


?oiteTior  broiiicli 


Airter.or  br. 


a  ' 


*>'     p     b'  \     ^''r^ , 

Kf  ^f"   ~  /     Lcngitud.naL 

-^j  J  -=4-^"^  cortical  column 


Anterior  cs\\\  ■>  ^  i 

Trcinsverse   section    of  L.  K. 

Fig.  840. — Showing  the  Blood-supply  of  the  Kidney  in  Relation  to  the  Kidney  Pelvis  and  Calyces. 

or  by  a  thickening  of  the  capsule  or  a  whitish  band  to  which  the  perirenal  fat  is 
more  intimately  attached  than  elsewhere. 

If  there  are  no  lobulations  or  furrows,  the  position  of  the  columns  of  Bertini 
may  be  shown  by  the  stellate  veins  in  the  capsule;  in  such  cases  they  are  unusually 


CONGENITAL    ABNORMALITIES    OF   THE   KIDNEY.  753 

conspicuous  and  are  arranged  in  rows  along  the  lines  where  lobulation  was  present 
during  fetal  life. 

Physiology. — Very  little  is  known  (Landois^)  of  the  nervous  influences  which 
govern  the  excretion  of  the  urine,  except  that  which  pertains  to  the  vasomotor 
nerves.  Whatever  dilates  the  vessels  of  the  glomeruli  of  the  kidney  increases 
the  excretion  of  urine.  This  need  not  be  true  if  adjacent  vascular  systems  are  also 
dilated,  for  then  the  blood-pressure  may  be  lowered.  The  center  for  the  vaso- 
motor fibers  of  the  kidney  is  found  in  the  floor  of  the  fourth  ventricle  in  front  of 
the  origin  of  the  vagus.  They  reach  the  kidney  through  the  renal  plexus,  which 
is  indirectly  connected  with  the  nerves  entering  into  the  solar  plexus,  namely,  the 
right  vagus  and  the  abdominal  splanchnic  nerves,  great  and  small. 


CONGENITAL    ABNORMALITIES   OF  THE  KIDNEY.^* 

The  kidneys  may  be  abnormal  in :  (a)  number,  (b)  form,  and  (c)  position. 

(a)  Number. — (1)  Both  of  the  kidneys  may  be  absent  in  monstrosities  incapable 
of  life.  (2)  One  kidney  may  be  absent;  with  this  there  is  usually  a  coincident 
malformation  of  the  accessory  organs  on  the  affected  side.  (3)  Rudimentary 
kidney;  one  kidney  may  be  incompletely  developed.  It  may  be  normal  in  form 
or  in  structure,  but  far  below  the  average  in  size;  it  may  show  lobulations  as  in 
fetal  life,  it  may  be  largely  made  up  of  fibrous  tissue,  or  it  may  be  altogether  atrophic. 
(4)  Supernumerary  kidney.  It  is  likely  that  many  of  the  reported  cases  are  in- 
stances of  a  mistake  in  diagnosis. 

(6)  Form. — (1)  Fetal  kidney;  a  small,  lobulated  organ.  Such  a  kidney  is  pre- 
disposed to  tuberculosis.  (2)  Horseshoe  kidney  (ren  arcuatus  s.  unguliformis). 
The  lower  poles  of  the  kidney  are  joined  so  as  to  form  an  organ  half-moon  or  horse- 
shoe-shaped, with  its  concavity  upward.  Rarely  the  upper  poles  are  united  and 
the  concavity  is  downward.  The  ureters  are  often  lengthened  and  course  over 
the  anterior  surface  of  the  organ.  The  vessels  of  the  kidney  are  increased  in 
number.  The  union  between  the  kidneys  may  be  formed  by  fibrous  tissue  or  by 
true  kidney  substance.  (3)  Unilateral  long  kidney  (ren  elongatis).  The  lower 
pole  of  the  upper  kidney  is  fused  with  the  upper  pole  of  the  lower  kidney.  The 
double  organ  lies  to  one  side  of  the  spinal  column.  The  hilus  of  each  kidney  is 
turned  to  the  same  side  in  the  simple  form,  or  to  opposite  sides  in  the  "S"  shaped 
form.  (4)  The  cake  or  shield-shaped  kidney  (ren  scutaneus).  The  kidneys 
are  represented  by  a  round  or  flattened  disc-like  body,  the  borders  of  which  exhibit 
indentations.  Such  a  kidney  usually  lies  in  the  median  line  of  the  body,  below  the 
normal  level.  As  a  rule  there  are  two  ureters.  (5)  The  lumpy  kidney  (ren  in- 
formis).  The  organ  is  irregular  and  is  formed  of  lobules  of  difi'erent  sizes  and 
shapes. 

(c)  Position. — Alterations  in  position  may  occur  in  the  case  of  a  single  kidney 

^  Landois:  "Text-Book  of  Human  Physiology,"  edited  by  Albert  P.  Brubaker,  Phila.,  1904. 
^  Kiister's  classification  has  been  followed. 
VOL.  II — 48 


754  SURGERY   OF   THE   KIDNEY. 

or  in  the  malformation  caused  by  a  fusion  of  the  kidneys;  or  the  otherwise  normal 
kidneys  may  be  permanently  displaced.  Alterations  in  position  occur  most  fre- 
quently, however,  in  fused  kidneys.  They  are  usually  in  the  median  line,  in  front 
of  the  great  vessels;  much  more  rarely,  and  only  in  certain  forms,  do  they  both  lie 
to  the  same  side  of  the  vertebral  column.  Even  when  in  the  median  hne  they  are 
at  a  lower  level  than  normal,  and  in  extreme  cases  they  may  he  in  the  hollow  of  the 
sacrum.  Then  the  ureters  are  short  and  the  renal  arteries  take  their  origin  from 
the  common  or  the  external  iliac.  A  displacement  of  this  type  may  be  the  source 
of  dystocia  in  labor. 

Much  more  rarely  a  single  well-formed  kidney  may  be  permanently  displaced. 
A  case  is  reported  in  which  the  right  kidney  lay  in  the  hollow  of  the  sacrum  to  the 
left  of  the  median  hne.     The  kidney  has  also  been  found  in  congenital  hernia. 


TRAUMATIC  INJURY  OF  THE  KIDNEY. 

Kidney  injuries  may  be  connected  with  open  wounds  or  they  may  be  subparietal. 

Etiology. — Penetrating  wounds  of  the  kidney  are  commonly  produced  either 
by  a  knife  or  a  bullet.  Subparietal  injury  of  the  kidney  may  be  the  result  of  either 
direct  or  indirect  violence.  Thus  a  thrust  or  a  blow  in  the  lumbar  region  or  be- 
neath the  costal  margin  anteriorly,  compression  of  this  part  of  the  body  between  two 
apposed  surfaces,  as  car-buifers,  or  a  crushing  pressure,  as  that  of  a  cart-wheel  pass- 
ing over  the  lumbar  region,  may  directly  injure  the  kidney.  Indirect  violence,  such 
as  the  jar  of  a  heavy  fall,  a  sudden  contraction  of  the  muscles  in  the  neighborhood 
of  the  kidney,  and  extreme  flexion  of  the  trunk,  may  indirectly  injure  the  kidney. 

A  kidney  injury  is  often  comphcated  by  a  fractured  rib  or  a  wound  of  an  adja- 
cent viscus. 

As  Keen^  has  pointed  r.  amatic  lesion  of  the  kidney  is  usually  unilateral; 

the  opposite  kidney  is  L  ,  and  any  surgical  work  necessitated  by  the  accident 

may  be  carried  out  ur  the  presumption  that  the  opposite  kidney  is  healthy 
and  can  supplement  the  work  of  the  injured  one. 

Pathology. — Penetrating,  Gunshot,  and  Stab  Wounds. — Penetrating  wounds 
of  the  kidney  are  frequently  complicated  by  injuries  to  the  adjacent  organs.  The 
wound  is  apt  to  contain  shreds  of  clothing  or  other  foreign  bodies.  The  injury 
may  involve  alone,  or  in  combination  the  kidney  tissue  itself,  the  kidney  pelvis, 
the  renal  blood-vessels,  and  the  ureter.  Wounds  which  involve  only  the  cortical 
renal  tissue  do  not  give  rise  to  extravasation  of  urine  or  to  much  hemorrhage. 
When,  however,  the  pelvis  or  the  calyces  are  wounded,  extravasation  of  urine  occurs 
and  bleeding  is  more  marked.  If  the  renal  vessels  are  torn,  the  hemorrhage  may 
be  fatal.  If  there  is  no  injury  to  the  peritoneum,  the  blood  will  either  escape  through 
the  ureter  or  pass  into  the  retroperitoneal  connective  tissue.  If  the  peritoneum 
is  wounded,  the  hemorrhage  may  be  intraperitoneal. 

1  Keen,  W.  W. :  "Treatment  of  Traumatic  Lesions  of  the  Kidney,  with  Tables  of  155  Cases," 
Ann.  Surg.,  1896,  xxiv,  p.  138. 


TRAUMATIC    INJURY   OF   THE   KIDNEY.  755 

It  is  very  rare  for  the  ureter  alone  to  be  wounded.  Other  organs  are  less  apt 
to  be  injured  in  stab  wounds  than  in  gunshot  injuries.  When  an  individual  is 
stabbed  in  the  kidney  region  from  the  front,  the  kidney  usually  escapes  injury.  A 
stab  wound  in  the  lumbar  region  may  be  complicated  by  a  protrusion  of  the  kidney 
through  the  wound. 

Subparietal  Injury;  Rupture  of  the  Kidney. — A  subparietal  injury  of  the  kid- 
ney, according  to  Keen,  may  vary  in  degree  as  well  as  in  extent.  It  may  consist 
of  a  more  or  less  extensive  bruise  of  the  renal  tissue  with  no  destruction  of  the  cap- 
sule or  solution  of  continuity  reaching  the  surface.  It  may  be  an  actual  tear  of  the 
capsule  as  well  as  of  the  renal  substance,  or  it  may  involve  the  renal  substance  alone. 
It  may  involve  not  only  the  renal  substance,  but  also  the  renal  pelvis,  so  that  the 
organ  may  even  be  torn  into  separate  pieces. 

While  the  smaller  vessels  necessarily  must  be  involved  in  every  bruise  or  tear, 
not  infrequendy  the  larger  ones  are  seriously  damaged,  and  rarely  the  kidney  is 
entirely  detached  from  them. 

The  ureter  may  be  torn  not  only  into  the  pelvis,  but  entirely  across,  so  that 
it  is  separated  from  the  organ;  and  the  kidney  not  only  may  be  ruptured,  but  even 
pulpified.  Along  with  a  rupture  of  one  kidney,  even  of  a  minor  degree,  the  peri- 
nephric tissue  itself  may  be  more  or  less  lacerated. 

The  amount  of  hemorrhage  and  of  urinary  extravasation  in  rupture  of  the  kidney 
depends  upon  the  location  and  the  extent  of  the  injury.  The  more  the  calyces  and 
the  kidney  pelvis  are  involved,  the  more  free  hemorrhage  and  urinary  extravasation 
there  will  be.  Even  in  severe  bruises  of  the  kidney  substance  the  hemorrhage 
is  limited  if  the  capsule  remains  intact,  or  if  there  are  firm  adhesions  between  the 
kidney  and  its  fatty  capsule.  Blood  or  urine  gaining  entrance  to  the  paranephric 
area  may  become  encapsulated  or  it  may  invade  the  retroperitoneal  connective 
tissue  involving  the  mesocolon,  the  mesentery,  the  inguinal  canal,  or  the  anterior 
abdominal  wall  about  the  external  ring. 

Hemorrhage  into  the  paranephric  tissue  may  be  so  exte  sive  as  to  endanger  life. 
If  the  peritoneum  is  torn,  hemorrhage  is  more  apt  to  be  serious,  and  sometimes  it  is 
fatal.  There  is  grave  danger  of  peritonitis  if  the  urine  is  not  entirely  bland.  Rup- 
ture of  the  peritoneum  is  more  common  in  adults  than  in  children,  because  there  is 
less  development  of  the  fatty  capsule  in  front  and  the  peritoneum  lies  more  directly 
in  relation  with  the  kidney. 

There  is  usually  hematuria  in  cases  of  ruptured  kidney.  As  a  rule,  the  blood  is 
mixed  with  the  urine,  but  occasionally  clots  are  formed.  The  hemorrhage  may  not 
be  apparent  externally  for  several  reasons:  The  ureter  may  become  plugged  with 
clots;  there  may  be  thrombosis  of  the  renal  vessels;  the  ureter  may  be  completely 
ruptured  or  it  may  be  the  seat  of  a  stenosis. 

The  danger  associated  with  a  case  of  ruptured  kidney  arises  primarily  from 
hemorrhage,  and  secondarily  from  infection.  Infection  may  involve  encapsulated 
collections  of  blood,  the  injured  and  devitalized  kidney  substance,  or  the  cellular 
tissue  infiltrated  with  urine. 


756  SURGERY  OF  THE  KIDNEY. 

Symptoms. — The  symptoms  of  a  traumatic  lesion  of  the  kidney  depend  upon 
the  nature  of  the  wound  and  the  exact  part  of  the  kidney  which  is  injured. 

In  gunshot  and  stab  wounds  of  the  kidney  the  position  of  the  wound  of  entrance 
and  the  direction  of  its  tract  may  indicate  kidney  involvement.  If  combined  with 
this  there  is  hematuria  or  a  discharge  of  urine  from  the  wound,  the  diagnosis  is 
almost  certain.  When  the  course  of  the  wound  is  not  clear,  hematuria  and  the 
symptoms  common  to  kidney  injuries  will  suggest  the  diagnosis.  Urinary  extra- 
vasation and  the  amount  of  hemorrhage  depend  on  the  part  of  the  kidney  involved. 
In  some  stab  wounds  of  the  kidney  the  diagnosis  may  be  facilitated  by  palpating 
the  kidney  through  the  wound.  Quite  frequently  when  the  wound  is  of  some  size 
and  has  been  inflicted  in  the  loin  below  the  ribs,  the  kidney  prolapses  into  the  wound. 

The  general  symptoms  of  a  kidney  injury  from  whatever  cause  vary  to  a  consider- 
able extent.  In  a  serious  case  they  are  usually  those  of  great  shock  and  severe 
collapse.  Prostration  is  marked.  The  face  is  pale  and  covered  with  cold  sweat. 
Vomiting  frequently  occurs.  The  patient  finds  a  position  which  lessens  the 
pain,  and  anxiously  guards  against  any  change  from  it.  The  first  symptom  may 
be  no  more  than  a  brief  faint,  without  any  general  indications  of  a  serious  injury, 
although  grave  symptoms  of  internal  hemorrhage  may  develop  subsequently 
after  the  patient  has  walked  or  ridden  for  some  distance. 

The  pain  in  these  cases  is  described  as  a  heavy,  nagging,  boring,  or  shooting 
pain  in  the  depths  of  the  lumbar  region,  radiating  in  various  directions,  but  especi- 
ally along  the  course  of  the  ureter.  Any  movement  or  any  local  pressure  increases 
it.  The  kidney  pain  must  be  distinguished  from  that  due  to  superficial  bruises  or 
lacerations,  or  from  associated  injury  to  the  ribs.  When  the  kidney  lesion  is  less 
serious,  the  pain  is  not  severe,  but  consists  of  a  dull  uneasiness  or  pressure,  which 
does  not  incapacitate  the  patient  for  work.  The  pain  may  be  of  a  sickening  charac- 
ter. Agonizing  renal  colic  occurs  at  times  and  is  indicative  of  the  passage  of  blood- 
clots  through  the  ureter.  The  respiratory  motions  are  limited,  the  belly  muscles 
being  contracted  and  the  surface  of  the  belly  hard. 

The  local  symptoms  include  ecchymoses  and  tumor  formation.  Superficial 
ecchymoses  in  the  lumbar  region  are  of  little  significance,  aside  from  indicating 
the  site  to  which  the  rupturing  force  was  applied;  they  are  caused  by  the  direct 
injury  of  the  superficial  tissues.  A  tumor  of  the  kidney  may  form  very  quickly 
and  be  easily  distinguished  by  palpation,  or  in  extreme  cases  by  inspection.  A 
tumor  may  develop  very  slowly,  or  in  less  serious  cases  may  not  occur  at  all. 

Late  evidences  of  deep  hemorrhage  are  found  in  bruise-like  discolorations  of 
the  skin  appearing  about  the  external  inguinal  ring;  they  are  due  to  an  infiltration 
of  blood  along  the  retroperitoneal  cellular  tissue  accompanying  the  spermatic  cord. 

Hematuria  occurs  in  considerable  amount  only  in  those  cases  in  which  the 
injury  has  involved  the  calyces  and  the  kidney  pelvis.  If  the  blood  remains  fluid 
as  it  passes  through  the  ureter,  the  bladder  fills  up  quickly,  and  upon  attempting 
to  urinate  the  patient  is  alarmed  at  passing  apparently  pure  blood;  or  it  may  be 
impossible  for  the  patient  to  pass  urine  on  account  of  insufficient  contraction  of 


TRAUMATIC    INJURY    OF   THE   KIDNEY.  757 

the  belly  muscles  due  to  reflex  inhibition  or  to  injury,  or  because  the  blood  in  the 
bladder  has  clotted.  In  a  large  majority  of  cases  hematuria  is  less  marked;  it 
may  be  only  microscopic.  Very  often  several  hours  elapse  after  the  injury  before 
the  patient  has  a  desire  to  urinate,  and  then  the  act  is  accomplished  with  pain  and 
the  urine  is  bloody.  Hematuria  may  not  appear  even  in  severe  injuries  if  the  condi- 
tions described  on  page  755  obtain. 

Hematuria  in  itself  is  not  pathognomonic  of  an  actual  rupture  of  the  kidney. 
It  may  be  the  result  of  a  simple  contusion  or  the  disturbance  of  a  quiescent  lesion 
existing  before  the  accident.  In  eighteen  cases  of  hematuria  noted  by  Morris 
the  symptom  persisted  for  three  weeks  in  two  cases,  and  from  three  to  eight  days  in 
the  others.  Hematuria  may  be  remittent.  After  one  or  two  evacuations  the  urine 
may  be  nearly  or  entirely  clear.  This  would  indicate,  as  a  rule,  slight  involvement 
of  the  kidney  calyces  and  pelvis.  In  all  severe  cases  hematuria  is  marked.  Very 
rarely  it  leads  to  death  within  twenty-four  hours.  In  fatal  cases  the  loss  of  blood 
persists  for  some  time,  perhaps  remittently,  the  patient  becomes  exhausted  grad- 
ually, and  at  length  a  more  marked  hemorrhage  ends  in  dissolution. 

There  is  usually  a  diminution  of  the  urinary  excretion  which  may  be  insignifi- 
cant or  marked,  depending,  as  a  rule,  upon  the  extent  of  the  lesion.  Rarely  polyuria 
may  ensue.  Anuria  may  be  an  evidence  that  the  bladder,  or  that  both  kidney 
pelves,  are  ruptured;  or  it  may  result  from  the  obHteration  of  the  renal  arteries; 
or  it  may  indicate  the  existence  of  but  one  kidney,  and  that  the  injured  one.  There 
is  a  form  of  anuria  which  apparently  is  reflex.  The  uninjured  kidney  sufi"ers  a 
contraction  of  its  vessels  due  to  an  irritation  of  the  vagus  and  the  splanchnic  nerves; 
the  excretion  of  urine  is  suspended  and  may  never  be  resumed.  If  the  bladder  is 
full  of  urine  at  the  time  of  the  accident,  the  symptoms  of  anuria  will  not  appear 
immediately.  The  reaction  of  the  urine  remains  acid  if  the  kidney  has  been  pre- 
viously healthy.  After  the  blood  disappears  from  the  urine,  there  may  be  albumi- 
nuria, caused,  according  to  Billroth,  by  traumatic  nephritis.  Traumatic  albumi- 
nuria may  occur  in  cases  of  kidney  injury  without  any  previous  hematuria. 

Prognosis. — According  to  Kiister,  nearly  one-half  of  all  kidney  injuries  cause 
death.     About  one-half  of  all  uncomplicated  kidney  injuries  end  in  recovery. 

Treatment. — The  first  eft'orts  of  the  physician  should  be  in  the  direction  of 
combating  shock  and  relieving  pain.  Rest  in  bed,  allowing  the  patient  to  take  the 
position  which  he  finds  most  comfortable;  cardiac  stimulants  to  overcome  the 
great  weakness;  and  hypodermic  injections  of  morphin,  should  be  prescribed. 
The  use  of  ergot,  gallic  acid,  etc.,  is  of  doubtful  value,  but  may  be  tried,  and  an 
ice-bag  should  be  placed  over  the  kidney  region. 

After  reaction  has  occurred,  the  subsequent  course  of  procedure  must  be  deter- 
mined, and  this  will  depend  upon  the  cause  and  the  extent  of  the  injury. 

When  the  general  symptoms  are  not  marked,  the  patient  reacts  quickly,  the 
wound  is  small  and  clean,  and  the  hemorrhage  is  not  alarming,  it  is  well  to  be  satis- 
fied with  thorough  cleansing  of  the  wound,  the  introduction  of  drainage,  and  the 
adoption  of  the  expectant  measures  already  described.     On  general  principles  all 


758  SURGERY   OF   THE   KIDNEY. 

penetrating  wounds  should  be  enlarged,  if  necessary,  to  permit  careful  inspection, 
thorough  cleaning,  the  removal  of  all  foreign  bodies,  and  the  introduction  of  free 
drainage.  If  the  position  of  the  wound  is  such  that  a  perforation  of  the  intestine 
is  strongly  suspected,  immediate  laparotomy  is  indicated. 

Gunshot  Injuries. — If  the  patient  does  not  react  promptly  or  has  progressive 
internal  hemorrhage  with  increasing  lumbar  hematoma  or  intraperitoneal  effusion, 
prompt  exploration  is  demanded.  This  should  be  an  abdominal  incision,  unless 
injury  of  the  other  viscera  of  the  abdomen  can  be  positively  excluded  and  the  hemor- 
rhage is  certainly  extraperitoneal.  After  exposing  the  kidney,  the  surgeon  must  be 
guided  by  the  conditions  which  are  present.  If  only  the  cortex  of  the  kidney 
has  been  wounded,  gauze  packing  should  be  used  to  arrest  hemorrhage  and  provide 
drainage.  If  the  large  blood-vessels  are  injured,  if  there  are  extensive  wounds 
of  the  pelvis,  or  if  the  kidney  is  completely  shattered,  nephrectomy  is  indicated. 
In  any  case  of  doubt  careful  cleansing  and  drainage  may  be  adopted. 

Rents  in  the  peritoneum,  if  clean,  should  be  closed;  but  if  the  wound  is  a  large 
one  and  much  urine  or  blood  has  escaped  into  the  abdominal  cavity,  it  will  be  safer 
to  perform  nephrectomy  and  provide  free  drainage,  preferably  through  the  loin. 

Collections  of  blood  from  the  paranephric  areas  should  be  thoroughly  evacuated. 
It  is  inadvisable  to  attempt  the  removal  of  collections  of  blood  within  the  layers 
of  the  mesocolon.  According  to  Keen,  such  a  course  usually  results  in  extensive 
injury  and  infection,  and  therefore  should  not  be  undertaken. 

Incised  or  Punctured  Wounds. — In  stab  wounds,  if  the  hemorrhage  is  very  free 
or  there  is  extravasation  of  urine,  the  opening  should  be  enlarged  and  the  organ 
carefully  examined.  Clean  wounds  of  the  kidney  may  be  immediately  sutured. 
Separated  portions  of  kidney  should  be  removed.  If  the  kidney  is  partly  shattered, 
a  partial  nephrectomy  may  be  done.  Clean-cut  wounds  of  the  pelvis  may  be  sutured 
at  once;  ragged  or  contused  ones  should  be  partially  closed  and  tubular  drainage 
provided. 

If  the  large  vessels  are  cut,  if  the  substance  of  the  kidney  itself  or  the  pelvis  is 
lacerated  beyond  the  point  where  the  organ  will  probably  recover  its  vitality  and 
resume  its  function,  immediate  nephrectomy  should  be  done.  The  kidney  must, 
of  course,  be  replaced,  if  it  has  prolapsed  through  the  wound. 

Suh'parietal  Injury. — In  the  treatment  of  a  subparietal  injury  of  the  kidney 
an  operation  is  indicated  if  there  are  evidences  of  persistent  hemorrhage.  Hemor- 
rhage occurring  into  the  paranephric  area  will  become  evident  through  the  rapid 
formation  of  a  hematoma  in  that  region.  If  the  blood  is  discharged  into  the  perito- 
neal cavity,  symptoms  of  internal  hemorrhage  will  be  associated  with  the  signs 
of  free  fluid  in  the  abdomen.  The  degree  of  hematuria  is  not  always  a  reliable  guide 
to  the  extent  of  an  injury,  but  if  large  quantities  of  nearly  pure  blood  are  passed 
through  the  urethra,  it  may  be  taken  as  an  indication  that  there  is  a  serious 
injury  which  demands  operation. 

The  abdominal  route  should  be  selected  for  the  operation  if  there  is  any  suspicion 
of  visceral  lesions  or  if  the  hemorrhage  is  intraperitoneal;    otherwise,  an  oblique 


TRAUMATIC   INJURY    OF   THE   KIDNEY.  759 

lumbar  incision  should  be  used,  and  this,  if  required,  may  be  extended  anteriorly 
to  a  sufficient  extent  to  permit  the  suturing  of  any  rents  in  the  peritoneum,  a  careful 
toilet,  and  the  introduction  of  drainage,  if  indicated. 

If  the  kidney  is  entirely  pulpified  or  if  the  renal  vessels  need  ligation  in  order  to 
arrest  hemorrhage,  immediate  nephrectomy  must  be  done.  Unless  an  abdominal 
incision  has  been  made,  when  the  uninjured  kidney  may  be  palpated,  nephrectomy 
will  have  to  be  performed  on  the  presumption  that  another  kidney  is  present. 

If  during  laparotomy  the  bladder  is  found  filled  with  blood-clots,  they  should 
be  expressed  through  the  urethra.  If  the  abdomen  has  not  been  opened,  the  clots 
in  the  bladder  may  be  removed  by  irrigating  with  salt  solution  through  a  large-eyed 
or  a  two-way  catheter  or  by  means  of  one  of  the  evacuators  used  in  litholapaxy. 
In  obstinate  cases  cystotomy  (suprapubic  in  the  male — vaginal  in  the  female)  may 
rarely  be  required. 

When  there  are  no  urgent  indications  for  a  primary  operation,  it  is  desirable 
to  place  an  ice-bag  over  the  affected  side  and  keep  the  patient  as  quiet  as  possible. 
If  the  intestines  are  distended,  a  high  compound  enema  should  be  administered. 
Nothing  but  enough  water  to  quench  the  thirst  should  be  given  by  mouth  for  the 
first  twenty-four  hours.  The  bladder  should  be  evacuated  at  regular  intervals 
and  appropriate  measures  should  be  adopted  to  avoid  retention  of  urine. 

When  anuria  occurs,  the  patient  should  be  encouraged  to  drink  freely  of  water; 
refrigerant  diuretics,  warm  applications  to  the  kidneys,  and  hot  saline  enemas 
should  be  used;  the  elimination  of  waste  products  should  be  assisted  by  hot  packs. 
If  the  anuria  persists  for  more  than  twenty-four  to  forty-eight  hours,  the  kidney 
should  be  exposed  by  means  of  a  lumbar  incision  and  the  calyces  and  pelvis 
opened. 

When  there  are  no  urgent  indications  for  primary  operation  in  a  case  of  sub- 
parietal  injury  of  the  kidney,  the  expectant  plan  of  treatment  already  outlined 
should  be  continued.  If  in  the  course  of  a  number  of  days  there  is  e\'idence  of  a 
considerable  collection  of  fluid  in  the  paranephric  area,  a  lumbar  incision  should  be 
made  immediately  and  the  parts  should  be  drained.  If  at  this  time  the  kidney  is 
found  to  be  hopelessly  injured,  it  should  be  extirpated.  Such  an  exploratory  lumbar 
incision  should  not  be  postponed  until  septic  symptoms  occur. 

In  the  absence  of  a  considerable  collection  of  fluid  in  the  lumbar  region,  any 
evidence  of  an  infectious  process  in  the  retroperitoneal  tissues  demands  lumbar 
incision  and  drainage. 

If  there  is  any  doubt  as  to  the  propriety  of  a  primary  operation  in  cases  of  kidney 
rupture,  an  exploratory  incision  should  be  made.  This  is  less  dangerous  than  an 
uncontrolled  hemorrhage.  A  partial  nephrectomy  up  to  one-third  of  the  kidney  is 
perhaps  justified,  and  the  results  are  encouraging;  the  mortality  is  33  per  cent. 
From  an  analysis  of  his  cases.  Keen  says:  "It  is  especially  to  be  noted  that  the 
great  mass  of  recoveries  in  rupture  of  the  kidney  are  the  slighter  cases;  the  graver 
ones  do  not  recover  unless  operation  is  done."  In  any  case,  therefore,  with  severe 
or  dangerous  symptoms,  the  surgeon  should  lean  toward  exploration,  and  in  severe 


760  SURGERY    OF   THE   KIDNEY. 

lacerations  toward  early  nephrectomy.     It  adds  little  to  the  risk  and  will  probably 
save  a  considerable  proportion  of  lives. 


ABNORMALLY  MOVABLE  KIDNEY.    FLOATING  KIDNEY.    NEPHROPTOSIS. 

In  health  the  kidneys  ascend  with  expiration  and  descend  with  inspiration, 
the  range  of  mobility  varying  from  1  to  H  inches  and  being  greater  in  the  female 
than  in  the  male. 

Abnormal  mobility  exists  in  different  degrees,  and  it  might  be  said  in  different 
kinds.  The  kidney  may  be  movable  behind  the  peritoneum  to  an  unusual  degree, 
so  that  half  to  two-thirds  of  it  is  palpable,  or  it  may  move  entirely  away  from  the 
costal  margin  and  advance  anteriorly  and  push  up  or  "float"  toward  the  abdominal 
wall. 

A  kidney  that  is  palpable  for  one-half  to  two-thirds  of  its  extent  is  spoken  of 
clinically  as  a  "movable"  kidney,  while  one  that  can  be  palpated  throughout  its 
extent  and  shows  a  tendency  to  ride  forward  in  the  abdominal  cavity  has  been 
designated  by  Morris  as  a  "floating"  kidney. 

This  is  not  the  anatomic  distinction.  Anatomically  a  floating  kidney  is  a  con- 
genital anomaly,  having  a  distinct  peritoneal  attachment  or  a  mesonephron.  Be- 
cause, however,  a  kidney  which  has  no  mesonephron  may  be  just  as  movable 
behind  the  peritoneum  and  may  float  as  far  anteriorly  as  one  that  has,  the  terms 
must  be  used  in  a  clinical  and  not  in  an  anatomic  sense. 

Frequency. — The  frequency  of  nephroptosis  in  women  is  variously  estimated 
by  different  authors.  Noble^  has  stated  that  it  occurs  in  25  per  cent,  of  women 
the  subject  of  gynecologic  diseases.  From  10  per  cent,  to  15  per  cent,  of  Beyea's^ 
gynecologic  patients  are  affected.  Harris^  saw  seventy-one  cases  of  movable 
kidney  in  one  hundred  and  twenty-six  women  examined  consecutively.  Hahn* 
found  eighteen  in  one  hundred  cases.  The  proportion  of  cases  noted  by  any  in- 
vestigator depends  on  the  class  of  patients  he  examines,  his  methods  of  diagnosis, 
and  his  conception  of  what  constitutes  an  abnormally  movable  kidney. 

Etiology. — Movable  and  floating  kidney  has  been  ascribed  to  many  causes: 
pregnancy,  tight  lacing,  emaciation  with  the  absorption  of  the  perirenal  fat,  trauma- 
tism, congenital  malformation  of  the  renal  fossa,  etc.  Equally  reliable  observers 
reach  different  conclusions  in  a  consideration  of  this  question.  Thus,  Hahn 
examining  one  hundred  women,  thirty-one  childless  and  sixty-nine  parous,  found 

1  Noble,  Charles  P.:  "Movable  Kidney,"  Gaillard's  Med.  Jour.,  1895,  vol.  Ixi,  p.  59;  "Some 
Further  Observations  Concerning  Movable  Kidney,"  Amer.  Jour.  Obst.,  1897,  vol.  xxv,  p.  63; 
"Nephrorrhaphy,"  Jour.  Amer.  Med.  Assoc,  1900,  vol.  xxxv,  p.  1517;  "The  Ultimate  Results 
of  Nephrorrhaphy,"  Internal.  Med.  Mag.,  1902,  vol.  xi,  p.  145;  "Some  of  the  More  Unusual 
Results  of  Movable  Kidney,"  N.  Y.  Med.  Jour.,  1904,  vol.  Ixxix,  p.  341. 

^  Beyea,  H.  D.:  "The  Significance  and  Treatment  of  Floating  Kidney  in  Women,"  Amer. 
Med.,  1901,  vol.  ii,  No.  21. 

^Harris,  M.  L.:  "The  Influence  of  Trauma  in  the  Production  of  Movable  Kidney,"  Jour. 
Amer.  Med.  Assoc,  1904,  vol.  xlii,  p.  411. 

^  Hahn,  E.:  "Die  operative  Behandlung  der  beweglichen  Niere  durch  Fixation,"  Cent.  f. 
Chir.,  1881,  Bd.  viii,  Nr.  29. 


ABNORMALLY    MOVABLE    KIDNEY.       FLOATING    KIDNEY.       NEPHROPTOSIS.       761 

eight  movable  and  eight  floating  kidneys.  They  all  occurred  in  the  women  who 
had  borne  children,  and  he  therefore  concludes  for  this  and  other  reasons  that 
pregnancy  is  the  chief  cause.  Harris  scouts  the  idea  of  nephroptosis  depending 
upon  pregnancy,  having  met  a  larger  percentage  of  cases  in  nulliparous  than  in 
parous  women.  Of  one  hundred  and  twenty-six  cases  examined,  there  were 
fifty-six  cases  in  which  the  kidney  was  not  palpable  and  seventy-one  in  which  it 
was  movable;  but  the  average  number  of  children  per  woman  was  greater  in  the 
first  class  than  in  the  second ;  out  of  one  hundred  and  seven  women  with  movable 
kidney,  fifty-two  had  no  children,  while  fifty-three  had  borne  one  or  more. 

Albarran  ranks  movable  kidney  with  the  stigmata  of  degeneracy.  Harris, 
although  he  does  not  go  that  far,  regards  an  alteration  of  the  body  form,  viz.,  a 
contraction  of  the  middle  zone  of  the  body,  as  the  most  potential  predisposing  factor 
in  movable  kidney. 

Glenard^  thinks  floating  kidney  is  but  part  of  a  general  ptosis  of  the  abdominal 
viscera — enteroptosis — due  to  an  abnormally  low  insertion  of  their  mesenteries  or 
points  of  attachment.  While  this  may  apply  to  the  very  rare  cases  of  floating 
kidney  with  a  mesonephron,  according  to  Ewald  and  H.  Morris,  it  does  not  apply  to 
ordinary  cases. 

Hahn  believes  that  acute  and  chronic  traumatism  may  be  concerned  in  the  pro- 
duction of  nephroptosis.  He  mentions  dancing,  horseback-riding,  and  muscular 
exertion  in  a  stooping  position. 

Harris,  who  critically  examined  forty-one  cases  of  abnormally  movable  kidney 
in  which  there  was  a  history  of  traumatism,  could  not  find  an  actual  relationship 
of  cause  and  effect  in  any  one  of  them. 

The  use  of  a  corset  has  been  mentioned  as  a  cause  of  ptosis  of  the  kidney. 
Trekaki  (quoted  by  Hahn)  examined  one  hundred  Arabian  women  who  used  no 
means  of  compression  of  the  waist;  in  thirty  the  lower  third  of  the  kidney  was 
palpable,  in  nine  the  lower  two-thirds,  and  in  two  the  kidney  floated. 

It  is  the  opinion  of  the  authors  that  the  difference  between  the  frequency  of 
floating  kidney  in  the  male  and  in  the  female  may  depend  entirely  upon  the  chffer- 
ence  in  the  configuration  of  the  renal  fossa.  In  the  man  they  are  deep,  narrowed 
below,  and  bean-shaped.  In  the  woman  they  are  shallow,  and  instead  of  being 
narrower  below,  especially  on  the  right  side,  they  are  actually  wider.  The  difference 
in  the  configuration  of  the  renal  fossa  must  be  associated  with  the  difference  in 
body  form  mentioned  by  Harris.  Morris  also  has  noted  that  the  type  which 
suffers  most  frequently  from  this  affection  is  the  spare,  slender,  small-waisted 
woman  with  a  long  thorax. 

Noble  has  been  particularly  impressed  with  the  relation  between  the  amount 
of  perirenal  fat  and  abnormal  mobility  of  the  kidney.  In  his  experience  rapid 
emaciation  in  women  not  confined  to  bed  has  been  a  factor  in  many  cases. 

Multiple  pregnancies,  diastasis  of  the  rectus  muscles,  and  relaxation  of  the  abdo- 

'  Glenard,  Frantz:  "Les  ptoses  visc^rales  (estomac,  intestin,  rein,  foie,  rate)  diagnostic 
et  nosographie  (enteroptose,  hepatisme)."    Paris,  1899. 


762  SURGERY    OF   THE    KIDNEY. 

minal  wall  may  be  contributing  causes,  but  they  are  more  closely  related  to  enter- 
optosis  than  to  nephroptosis. 

It  seems  reasonable  to  believe  in  a  small  number  of  cases  that  traumatism  has 
produced  a  floating  kidney;  especially  when  the  left  kidney  is  affected,  the  right 
organ  being  in  situ. 

Other  causes  have  been  noted,  such  as  tumors  about  the  upper  pole  of  the  kid- 
ney, downward  displacement  of  the  diaphragm  by  pulmonary  disease,  increase  in 
the  weight  of  the  kidney  as  in  hydronephrosis,  etc.,  and  high-heeled  shoes  which 
throw  the  body  forward  and  produce  a  compensatory  lumbar  lordosis. 

Pathology. — The  kidney  may  be  entirely  healthy  or  it  may  be  the  seat  of 
various  diseases,  which  are  either  the  result  or  the  cause  of  the  ptosis  or  purely 
accidental. 

A  certain  degree  of  softness  or  flabbiness  of  the  renal  tissue,  due  to  sacculation  of 
the  calyces  from  intermittent  renal  distention,  is  spoken  of  by  H.  Morris.  It  is  seen 
in  the  cases  of  beginning  hydronephrosis  brought  about  by  a  twisting  or  a  kinking  of 
the  ureter. 

i\.s  a  result  entirely  of  faulty  position  and  a  periodic  interruption  of  its  normal 
discharge,  the  kidney  may  contain  calculi  or  an  abscess,  or  it  may  be  the  seat  of 
any  form  of  nephritis. 

That  pathologic  mobility  of  the  kidney  may  produce  nephritis  is  indicated  by 
the  report  of  Edebohls,  who  found  it  in  seventeen  cases  out  of  one  hundred  and 
eighty-six;   in  nine  cases  both  kidneys  were  affected. 

Tuberculosis  has  been  found.  Torsion  of  the  pedicle  sometimes  results  in  con- 
gestion of  the  kidney  and  hematuria. 

A  displaced  kidney  may  pull  down  the  duodenum,  and  this  in  turn  the  bile- 
ducts,  favoring  gastric  dilatation  and  disturbance  in  the  biliary  function.  Accord- 
ing to  Edebohls,  a  ptosed  kidney  may  press  upon  the  ileocolic  branch  of  the  superior 
mesenteric  artery,  predisposing  to  congestion  of  the  appendix  and  chronic  ap- 
pendicitis. 

Symptoms. — The  subjective  symptoms  of  movable  kidney  are  reflex  and  local. 
In  many  cases  they  are  reflex  and  not  at  all  characteristic.  The  most  prominent 
reflex  symptoms  are  nervousness,  intestinal  indigestion,  distention  of  the  bowel, 
palpitation  of  the  heart,  and  cardialgia.  Neuralgic  areas  are  met  with  frequently 
and  the  pain  is  referred  most  often  to  the  abdomen  and  the  region  of  the  heart. 

One  of  the  common  local  symptoms  is  a  sensation  of  weight  or  dragging,  which 
is  noticed  after  standing  or  walking  for  a  long  time.  In  certain  cases  the  patient 
finds  the  ptosed  kidney  and  recognizes  it  as  a  source  of  annoyance  and  even  pain. 
A  common  symptom  is  inability  to  sleep  lying  on  the  side  opposite  the  affected 
kidney. 

Constant  pain  in  the  kidney  itself  is  not  a  frequent  symptom,  but  acute  attacks 
of  severe  pain  occur  in  many  of  the  well-marked  cases,  being  the  result  of  torsion 
of  the  pedicle  of  the  kidney  which  obstructs  the  blood-vessels,  the  ureter,  or 
both. 


ABNORMALLY   MOVABLE   KIDNEY.       FLOATING    KIDNEY.      NEPHROPTOSIS.       763 

Such  attacks  are  spoken  of  as  renal  or  Dietl's  crises.^  The  patient  is  seized  with 
sharp,  agonizing  pain,  and  there  is  great  tenderness  in  the  himbar  and  hypochondriac 
regions.  As  a  rule,  the  kidney  rapidly  enlarges  and  can  be  more  or  less  distinctly 
mapped  out,  the  increase  in  size  being  due  either  to  an  extreme  congestion  of  the 
blood-vessels  or  to  an  acute  hydronephrosis,  or  to  both.  The  attack  is  accom- 
panied usually  by  marked  nausea  and  vomiting. 

During  renal  or  Dietl's  crises  the  urinary  excretion  is  diminished,  and  contains 
albumin,  casts,  or  even  blood.  These  substances  disappear  afterward,  and  there 
is  apt  to  be  an  increased  discharge  of  urine,  especially  if  an  acute  hydroureter  or 
hydronephrosis  has  developed.  Between  the  attacks  of  renal  colic  the  urine  may 
be  entirely  normal.  In  a  single  instance  one  of  us  observed  hematuria,  the  result 
of  chronic  congestion  from  torsion  of  the  renal  vessels.  Congestion  of  the  kidney 
is  responsible  also  for  the  albumin  and  the  hyaline  casts  which  sometimes  appear  in 
the  urine. 

In  rare  instances  intestinal  obstruction,  jaundice,  or  dilatation  of  the  stomach 
has  occurred  from  pressure  or  traction  upon  the  duodenum. 

Diagnosis. — The  frequency  with  which  the  diagnosis  of  nephroptosis  is  made 
depends  to  some  extent  upon  the  view  of  the  examiner  as  to  what  constitutes  an 
abnormal  range  of  mobility. 

The  kidney  normally  is  not  palpable,  or  at  least  no  more  than  its  lower  border 
can  be  felt.     Nephroptosis  has  been  said  to  exist  in  three  degrees: 

1.  The  lower  half  of  the  kidney  is  palpable. 

2.  The  greater  part  or  the  whole  of  the  kidney  is  palpable. 

3.  The  whole  kidney  descends  below  the  border  of  the  ribs. 

It  has  been  observed  by  Clark  and  one  of  the  authors  that  the  kidney  has  a 
normal  range  of  mobility  which  varies  between  3  and  5  cm.  This  has  been  deter- 
mined by  direct  intra-abdominal  palpation  during  celiotomy.  Many  cases  of  the 
first  degree,  therefore,  must  remain  of  questionable  importance.  As  a  rule,  not 
much  significance  need  be  attached  to  any  case  in  which  the  kidney  cannot  be 
easily  brought  below  the  costal  margin. 

Neurasthenic  and  hysterical  symptoms  are  often  associated  with  loose  kidney. 
It  is  an  important  point  in  judging  a  case  to  separate  the  nervous  symptoms  which 
are  due  to  the  kidney  from  those  due  to  enteroptosis  and  others  which  may  exist 
coincident  with  but  independent  of  the  renal  displacement. 

Most  of  the  writers  upon  this  subject  examine  for  movable  kidney  with  the 
patient  lying  on  her  back  or  the  side  opposite  the  displaced  organ.  The 
thighs  of  the  patient  are  flexed  and  elevated  over  pillows.  The  examiner  stands 
upon  the  side  involved  and  places  the  palmar  surface  of  his  outer  hand  under  the 
lower  costal  margin  and  presses  forward.  The  other  hand  is  applied  with  its  pal- 
mar surface  upon  the  abdominal  wall,  the  finger-tips  lying  just  below  the  ribs  and 
outside  of  the  rectus  muscle.     The  patient  is  now  directed  to  inspire  deeply  and  to 

^Dietl:  "Wandernde  Nieren  und  deren  Einklemmung,"  Wiener  med.  Wochenschr.,  1864, 
Bd.  xiv,  Nr.  36,  37  und  38,  S.  563,  579  und  592.. 


764  SURGERY  OF  THE  KIDNEY. 

follow  this  with  a  quick,  relaxing,  sighing  expiration;  during  the  latter  the  fingers 
gently  press  the  abdominal  wall  inward  and  the  whole  hand  is  moved  downward. 
In  this  way  the  kidney  brought  down  by  deep  inspiration,  if  abnormally  movable, 
may  be  felt  slipping  upward  between  the  fingers.  In  order  to  determine  whether  it 
can  be  palpated  in  toto,  the  thumb  of  the  posterior  hand  just  before  the  expiratory 
effort  may  be  pushed  deeply  under  the  costal  arch  anteriorly,  thus  preventing  the  re- 
turn of  the  kidney  during  expiration  and  enabling  the  examiner  to  palpate  its  surface 
at  leisure.  All  authors  speak  of  the  uncertainty  of  this  method  of  examination  and 
advise  repeated  exminations  at  intervals  of  several  days,  in  case  the  first  examina- 
tion is  negative.     Having  the  patient  cough  or  strain  will  sometimes  bring  the  kidney 

down. 

Owing  to  the  defects  of  the  usual  method  of  examination.  Noble  devised  a  plan 
of  examining  the  patient  in  the  erect  posture.  This  method  is  not  only  very  trust- 
worthy in  determining  whether  or  not  the  kidney  is  ptosed,  but  it  affords  a  reliable 
means  also  of  learning  the  range  of  mobility.  With  the  patient  in  the  dorsal  position 
an  abnormally  movable  kidney,  as  a  rule,  resumes  its  normal  position  and  is  dis- 
placed only  by  inspiratory  effort;  in  the  erect  posture,  on  the  other  hand,  it  becomes 
displaced  by  gravity.     The  examination  should  be  made  as  follows : 

The  patient's  clothing  should  be  loosened,  all  bands  about  the  waist  unfastened, 
and  the  skirts  supported  by  a  nurse  or  assistant,  so  that  the  patient  will  not  be 
embarrassed  with  the  fear  that  her  clothing  will  fall  off.  She  should  then  stand 
before  a  table  or  a  desk  of  convenient  height — about  30  inches — with  the  examiner 
seated  on  her  right.  The  patient  then  bends  forward  from  the  hips,  and  supports 
some  of  her  weight  by  resting  her  hands  on  the  table.  She  is  directed  to  respire 
regularly,  care  being  taken  to  relax  herself  thoroughly  during  expiration.  The 
examiner's  left  hand  is  placed  against  the  lumbar  region  posteriorly,  and  his  right 
hand  in  a  corresponding  position  in  front  of  the  kidney.  By  a  conjoint  manipula- 
tion the  region  between  the  two  hands  can  be  carefully  palpated,  and,  if  present, 
the  kidney  is  easily  recognized.  The  points  to  be  noted  are  the  shape  and 
size  of  the  kidney,  its  ready  displacement  upward  beneath  the  margin  of  the  ribs 
and  return  to  its  former  location  as  soon  as  the  examiner's  hands  no  longer  support 
it.  When  the  kidney  is  compressed,  as  a  general  rule,  the  patient  will  complain  of 
tenderness  or  pain  of  a  peculiar  character,  often  associated  with  a  feeling  of  faint- 
ness  or  nausea.  Upon  the  right  side,  as  mentioned  by  Hahn,  a  ptosed  kidney 
must  be  differentiated  from  a  movable  "Schnur"  lobe  of  the  liver  and  a  tensely 
filled  gall-bladder,  and  on  the  left  side  from  an  abnormally  movable  and  enlarged 
spleen.     Tumors  of  the  bowel  might  also  be  a  source  of  error. 

Indications  for  Operation. — Only  a  small  minority  of  cases  of  movable  kidney 
require  nephropexy.  Many  cases  of  abnormally  movable  kidney,  even  marked 
cases,  produce  no  symptoms.  On  the  other  hand,  a  moderate  ptosis  may  cause  a 
great  deal  of  suffering.  Nephropexy  is  not  only  indicated,  but  is  urgently  demanded 
in  cases  having  marked  local  symptoms,  such  as  renal  crises,  intermittent  hydro- 
nephrosis, constant  pain  or  soreness  in  the  kidney,  and  albumin  or  casts  of  blood 


HYDRO-,    URO-,    CYSTONEPHROSIS,    SAC-KIDNEY    OF   KUSTER.  765 

in  the  urine.  Operation  may  be  advisable  also  when  the  ptosed  kidney  is  recog- 
nized by  the  patient  as  an  annoying  movable  tumor. 

When  the  symptoms  are  reflex,  especially  when  the  kidney  is  displaced  only  to 
the  first  or  the  second  degree,  it  is  wise  to  try  the  effect  of  medical  and  hygienic 
treatment.  In  our  experience  the  rest  cure  has  proved  curative  in  certain  cases 
and  obviated  the  necessity  for  operation.  When  the  patient  remains  upon  her 
back,  the  kidney  returns  to  its  normal  position,  and  with  the  increase  of  perirenal 
fat  brought  about  by  rest  and  forced  feeding  a  permanent  cure  may  be  effected, 
especially  in  cases  of  the  first  or  even  of  the  second  degree.  In  others,  hygienic 
and  tonic  management  has  improved  nutrition  and  increased  the  deposit  of  fat, 
and  relief  has  been  obtained. 

The  treatment  of  movable  kidney  by  means  of  belts  and  pads  is  advocated  by 
some,  including  Treves.  This  treatment  seems  irrational,  and  the  cases  which 
have  come  under  the  observation  of  the  authors  have  not  been  benefited.  A  physi- 
cian who  suffered  with  nephroptosis  and  had  hematuria  therefrom  for  eight  years 
stated  that  he  could  keep  his  kidney  in  position  by  means  of  a  belt  and  pad,  and  yet 
fixation  of  the  kidney  by  operation  caused  the  hematuria  to  disappear  and  also 
demonstrated  the  inefficiency  of  the  previous  treatment. 

The  use  of  special  corsets  of  the  so-called  straight-front  variety  is  a  much  more 
satisfactory  means  of  palliative  treatment,  and  they  are  especially  useful  in  cases 
of  enteroptosis  associated  with  movable  kidney.  By  supporting  the  abdominal 
contents  some  indirect  support  is  afforded  the  kidney.  The  use  of  a  straight-front 
corset  is  indicated  in  cases  having  well-marked  nervous  symptoms.  The  effect 
of  the  support  which  the  corset  affords  will  help  to  differentiate  between  symptoms 
which  really  are  due  to  nephroptosis  and  those  caused  by  enteroptosis,  neurasthenia, 
and  hysteria. 

Nephropexy  is  indicated  when  the  reflex  symptoms  are  distressing  and  sympto- 
matic treatment  has  given  no  relief.  Non-operative  treatment  will  usually  fail  in 
cases  of  this  sort  when  the  kidney  is  displaced  to  the  third  degree.  Operation 
should  be  avoided  when  the  patient  is  pronouncedly  neurotic  or  hysterical.  Should 
the  local  symptoms  directly  referable  to  the  kidney  itself  demand  operation  in 
patients  of  this  type,  the  prognosis  should  be  guarded,  and  the  patient  herself, 
or  even  better  her  family,  should  be  made  to  understand  that  the  operation  will 
remove  the  local  but  not  the  hysterical  symptoms. 


HYDRONEPHROSIS,  URONEPHROSIS.   CYSTONEPHROSIS,   SAC-KIDNEY  OF 

KUSTER. 

Etiology  .^Hydronephrosis  may  be  congenital  or  acquired. 

The  congenital  form  is  present  at  birth  or  soon  after.  There  may  be  malforma- 
tion of  the  calyces  or  the  pelvis  of  the  kidney,  but  the  usual  location  of  a  congenital 
obstruction  is  the  ureter.  The  latter  may  end  blindly  or  it  may  be  the  seat  of  a 
complete  or  a  partial  stricture.     Malformation  may  be  present  at  the  ureterovesical 


766  SURGERY  OF  THE  KIDNEY. 

or  the  ureteropelvic  junction.  There  may  be  valves  or  twists  in  the  ureter.  It 
may  have  too  oblique  or  too  high  an  insertion  into  the  kidney  pelvis.  The  ureter 
may  be  kinked  over  anomalous  kidney  vessels  or  the  kidney  may  be  congenitally 
displaced  with  the  same  result.  Congenital  tumors  of  the  ureter,  the  bladder,  or 
the  neighboring  organs  are  causes.  Finally,  phimosis  or  obstruction  of  the 
urethra  may  produce  hydronephrosis. 

Acquired  hydronephrosis  may  be  the  result  of  traumatism  inflicted  upon  the 
kidney  pelvis  or  the  ureter  and  subsequent  displacement,  adhesions,  distortion,  or 
cicatricial  contraction.  Hydronephrosis  due  to  this  cause  may  appear  years  after 
the  injury.  Inflammatory  or  other  processes  in  the  neighborhood  of  the  ureters, 
especially  about  the  ureters,  such  as  parametritis,  fibroid  tumor,  and  cancerous 
infiltration  of  the  broad  ligaments,  may  lead  to  compression  of  the  ureter  and 
resulting  hydronephrosis.  Ureteritis  from  tuberculosis  or  gonorrhea  may  act  as 
an  exciting  cause;  the  same  is  true  of  ureteral  or  periureteral  abscess.  Schede^ 
regards  gonococcus  stricture  as  the  most  frequent  source  of  obstruction  due  to  in- 
flammatory lesions. 

Stones  in  the  renal  pelvis  or  in  the  ureter,  producing  either  incomplete  or  incon- 
stant obstruction  to  the  outflow  of  urine,  are  undoubtedly  causative  in  many  in- 
stances. At  the  time  the  hydronephrotic  tumor  comes  under  observation  there 
may  be  no  calculus,  but  scars  are  to  be  found  which  indicate  the  former  site  of  one, 
the  ulceration  caused  by  it  having  subsided  when  the  stone  was  passed. 

Kiister  believes  that  pyelitis  is  a  frequent  source  of  valve  formation.  The  mucous 
membrane  of  the  ureter  and  the  kidney  pelvis  becoming  swollen,  there  is  some 
obstruction  to  the  urinary  outflow  and  an  increase  of  intrapelvic  pressure.  The 
latter  forces  the  movable  mucosa  of  the  pelvis  downward  and  invaginates  it  into 
the  narrow  ureteral  orifice. 

Hydronephrosis  is  sometimes  intimately  related  to  floating  kidney.  In  three 
hundred  and  thirty-six  cases  of  acquired  hydronephrosis  not  due  to  stone,  Kiister 
estimated  that  one  hundred  and  twenty-seven  at  least  were  caused  by  it.  In 
arriving  at  this  conclusion  he  considered  only  those  cases  of  intermittent  hydro- 
nephrosis which  were  positively  stated  to  be  abnormally  movable.  Possibly 
more  than  half  of  the  cases  of  cystonephrosis  are  produced  by  a  floating  kidney, 
and  the  obstruction  is  brought  about  through  a  kinking  of  the  ureter.  Ureteral 
stricture,  vesical  cancer,  and  prostatic  enlargement  may  cause  hydronephrosis. 
The  same  has  been  said  of  an  irritable  bladder,  which  contracts  and  frequently 
attempts  to  express  its  contents. 

When  the  obstruction  is  located  below  the  ureterovesical  junction,  hydronephro- 
sis is  usually  bilateral. 

As  noted  by  Fenger,^  a  slowly  developing  incomplete  or  intermittent  obstruction 

is  most  favorable  for  the  development  of  a  hydronephrosis  and  is  the  almost  invaria- 

*  Schede,  M.:  "Diseases  of  the  Kidney,"  System  of  Practical  Surgery,  v.  Bergmann;  Ed. 
by  W.  T.  Bull,  Phila.,  1904,  p.  262. 

^  Fenger,  Christian:  "Conservative  Operative  Treatment  of  Sacculated  Kidney — Cysto- 
nephrosis," Ann.  Surg.,  June,  1896,  xxiii,  637. 


HYDRO-,    URO-,    CYSTONEPHROSIS,    SAC-KIDNEY   OF   KUSTER.  767 

ble  cause.  When  the  ureter  is  more  or  less  quickly  and  entirely  occluded,  the  back 
pressure  of  the  urine  in  the  kidney  causes  a  diminution  and  finally  a  cessation  of 
excretion,  and  the  resulting  hydronephrosis  usually  will  not  be  of  much  size.  The 
large  hydronephrotic  sacs  are  produced  by  intermittent  gradually  induced  obstruc- 
tion. This  explains  some  of  the  cases  of  hydronephrosis  which  develop  during 
adult  life  and  are  really  due  to  congenital  causes.  Cases  of  hydronephrosis  involv- 
ing only  a  part  of  the  kidney  are  found  in  malformations  where  there  are  two  pelves 
or  two  ureters  and  one  of  them  has  become  obstructed. 

Pathologic  Anatomy  of  Hydronephrosis. — The  obstruction  to  the  outflow 
of  urine  in  a  majority  of  the  cases  of  hydronephrosis  is  located  at  or  near  the  uretero- 
pelvic  junction.  This  is  true  at  least  of  the  patients  who  come  under  the  observa- 
tion of  the  surgeon  and  are  treated  surgically.  Any  constant  impediment  to  the 
passage  of  urine  through  the  ureter  favors  distention  of  the  kidney,  by  raising  the 
pressure  within  the  kidney  pelvis  and  within  the  ureter  above  the  point  of 
obstruction.  Hydronephrosis  due  to  diseases  of  the  pelvic  organs,  partial  stric- 
ture of  the  ureter,  stone,  etc.,  are  readily  explained  in  this  way. 

Hydronephrosis  when  caused  by  a  movable  kidney  is  primarily  due  to  a  kink 
in  the  ureter.  At  first  obstruction  is  temporary,  and  when  the  kidney  falls  back 
into  its  normal  position  the  free  outflow  of  urine  is  re-established.  As  these  attacks 
are  repeated,  however,  the  pelvis  remains  more  and  more  dilated  and  the  ureteral 
kink  is  less  completely  effaced  after  the  attack  is  over;  adhesions  may  form;  grad- 
ually these  changes  become  permanent,  and  finally  there  is  complete  retention. 

Hydronephrosis  not  due  to  abnormally  movable  kidney  nor  to  well-recognized 
sources  of  obstruction  may  originate  in  a  catarrhal  swelling  of  the  mucosa  of  the 
kidney  pelvis,  obstructing  the  ureteral  opening. 

Whatever  the  original  cause  of  the  obstruction  may  be,  after  the  pelvis  of  the 
kidney  has  become  distended  to  a  certain  extent  it  presses  upon  and  distorts  the 
upper  part  of  the  ureter.  Schede  explains  this  by  noting  that  it  is  easier  for  the 
kidney  pelvis  to  expand  downward  and  forward  than  in  any  other  direction,  just 
as  if  it  were  made  of  india-rubber  and  much  thinner  in  its  lower  part  than  elsewhere. 
As  a  result  of  the  distention  of  the  pelvis  downward,  the  uretero-pelvic  junction  is 
carried  upward  and  inward;  the  ureter  is  made  to  enter  the  pelvis  at  a  very  acute 
angle  (see  Fig.  843)  and  the  lower  margin  of  the  opening  forms  a  valve  which  in 
advanced  cases  effectually  prevents  the  outflow  of  urine. 

The  distention  in  hydronephrosis  may  affect  one  or  several  calyces,  one  or  both 
halves  of  a  divided  pelvis,  or  most  commonly  there  may  be  a  dilatation  of  the  entire 
kidney  pelvis  and  calyces.  When  limited  to  one  or  two  calyces,  the  distention  is 
almost  always  due  to  a  stone,  which  has  caused  an  ulceration  of  the  free  borders  of 
a  calyx,  the  ulcer  finally  contracting  to  a  ring  of  scar  tissue.  Hydronephrosis 
affecting  one  half  of  a  divided  pelvis  usually  is  associated  with  double  ureters. 

In  the  common  form  the  pelvis  of  the  kidney  becomes  dilated  first,  forming  a 
pear-shaped  tumor  (Fig.  841) ;  the  calyces  next,  and  finally  the  medulla  and  the  cortex 
of  the  kidney  are  thinned  and  stretched  out.     The  parenchyma  of  the  organ  atro- 


768 


SURGERY    OF   THE   KIDNEY. 


renal  vein. 


phles  more  or  less  completely,  until  at  last  the  kidney  is  represented  by  an  irregular 
cystic  tumor,  in  whose  walls  are  found  the  remnants  of  the  original  kidney  tissue. 
While  many  cases  in  their  ultimate  stage  consist  of  actual  unilocular  sacs, 
others  are  multilocular,  the  individual  cysts  usually  communicating  with  each  other, 
however,  by  very  small  openings.  These  openings  represent  the  mouths  of  the 
erstwhile  calyces  and  have  a  tendency  to  contract  and  form  a  cicatricial  ring. 
The  wall  of  the  sac  may  be  thin  and  transparent  in  the  area  representing  the  orig- 
inal kidney  pelvis;  or  it  may  be  thick  and  have  a 
turbid  white  color;  or  it  may  be  very  thick  and  con- 
tain deposits  of  lime. 

The  ureter  may  adhere  to  the  sac  wall  for  some 
distance.  The  adhesions  may  be  separated  in  early 
cases,  but  not  in  old  ones. 
The  ureter  may  run  for  quite 
a  distance  in  the  wall  of  the 
sac,  to  terminate  at  a  point 
high  over  its  lower  pole.  A 
valve  formation  is  often  pres- 
ent, so  that  the  ureteral  open- 
ing is  difficult  or  impossible 
to  discover  from  within  the 
sac,  even  in  removed  speci- 
mens. Sometimes  the  open- 
ing can  be  found  only  by 
means  of  sounding  or  sHtting 
the  ureter  from  below. 

The  hydronephrotic  sac 
may  be  no  larger  than  the 
normal  kidney,  or  it  may  be 
sufficiently  large  to  form  a 
well-marked  tumor  in  the 
kidney  region.  Rarely  it  may 
be  smaller  than  the  normal 
kidney,  or  of  such  a  size  that 
it  occupies  a  great  part  of 
the  abdominal  cavity. 
Contents  of  the  Kidney  Sac. — Except  in  recent  cases,  hydronephrotic  fluid 
does  not  have  the  characteristics  of  normal  urine;  it  is  practically  httle  more  than 
water  containing  sodium  chlorid  and  a  few  desquamated  epithehal  cells  and  fat 
droplets.  The  urine  in  fresh  cases  loses  its  solid  constituents  pari  passu  with  the 
gradual  atrophy  of  the  kidney  parenchyma.  The  specific  gravity  sinks  to  1.010 
or  even  to  1.0065.  The  reaction  becomes  weakly  acid  or  neutral.  The  urine 
may  be  watery  or  of  a  dark  yellow,  yellowish-brown,  or  greenish  color;    it  may 


Fig.  841. — Hydronephrosis. 

Note  the  constriction  an  inch  below  the  uieteropelvic 

junction. 


HYDRO-,    URO-,    CYSTONEPHROSIS,    SAC-KIDNEY    OF   KUSTER.  769 

be  a  little  turbid  or  entirely  clear.  Fresh  blood  colors  the  fluid  a  light  or  dark  red; 
old  blood  gives  it  a  chocolate  or  coffee  color.  The  contents  may  be  tenacious  col- 
loid material  or  thick  and  pasty,  Uke  white  paint  or  putty;  numerous  cholesterin 
crystals  are  sometimes  found. 

Symptoms. — The  subjective  symptoms  which  present  themselves  before  the 
appearance  of  a  tumor  vary  to  a  considerable  extent,  being  influenced  by  the  cause 
and  the  mechanics  of  the  distention.  In  a  large  number  of  congenital  cases  there 
are  no  symptoms  until  the  kidney  tumor  is  found. 

In  the  intermittent  form  associated  with  abnormal  mobility  of  the  kidney  and 
a  kinking  of  the  ureter,  the  patient  will  suffer  from  repeated  attacks  of  renal  colic, 
followed  by  an  increased  discharge  of  urine  as  the  pain  subsides.  The  develop- 
ment of  hydronephrosis  due  to  ureteral  or  to  kidney  stone  is  usually  preceded  or 
accompanied  by  the  symptoms  of  those  conditions.  Cases  of  hydronephrosis 
which  are  secondary  to  urethral  stricture,  enlarged  prostate,  pelvic  carcinoma,  etc., 
usually  present  the  associated  symptoms  of  the  primary  lesion.  Distention  of  the 
kidney  from  non-inflammatory  or  non-malignant  external  pressure  on  the  ureter, 
as,  for  example,  in  the  case  of  a  subperitoneal  fibroid  or  a  pregnant  uterus,  may  be 
quite  painless  until  a  considerable  size  has  been  attained.  In  the  intermittent 
variety  of  hydronephrosis  there  may  be  gastro-intestinal  symptoms,  such  as  diges- 
tive disturbance,  nausea,  anorexia,  and  constipation.  Sometimes  the  patient  will 
have  complained  of  a  feeling  of  pressure  or  uneasiness  for  a  time  before  the  tumor  is 
found. 

The  position  of  the  tumor  in  hydronephrosis  will  depend  upon  its  size  and  its 
mobility.  In  the  case  of  a  small  tumor  with  no  increase  of  mobility,  the  enlarged 
kidney  will  be  found  in  its  normal  position.  When  the  tumor  is  mobile  and  is 
displaced  downward,  it  will  usually  occupy  a  position  in  the  ileocostal  area,  pressing 
the  abdominal  parietes  forward  and  outward.  It  may  be  evident  upon  inspection. 
The  colon  lies  in  front  of  the  tumor,  unless  the  latter  is  very  large,  when  the  bowel 
may  be  displaced  to  one  side  and  the  tumor  be  in  direct  relation  with  the  anterior 
abdominal  wall.  In  very  large  collections  of  fluid,  the  enlarged  kidney  may  extend 
beyond  the  median  line  of  the  abdomen. 

On  palpation  the  tumor  may  be  flaccid  or  tense.  It  is  very  often  slightly  irregu- 
lar in  outline  and  may  even  be  lobulated.  Fluctuation  is  present  if  the  tumor  is  of 
large  size,  the  sac  tense,  and  the  walls  thin.  Some  flaccid  tumors  cannot  be  dis- 
tinctly outhned.  If  the  hydronephrosis  is  small  and  tense,  it  may  feel  like  a  solid 
tumor. 

During  palpation  the  tumor  may  suddenly  become  soft  and  yielding,  and  the 
patient  may  at  once  express  a  desire  to  urinate,  when  an  unusually  large  amount  of 
urine  may  be  passed  from  the  bladder.  In  such  a  case  pressure  has  overcome  the 
obstruction  and  the  hydronephrotic  fluid  has  been  expressed  through  the  ureter. 
The  same  phenomenon  may  occur  spontaneously  in  intermittent  hydronephroses 
when  the  obstruction  is  valvular  and  very  wide  distention  of  the  sac  opens  the  valves. 
The  hydronephrotic  sac  occasionally  ruptures,  either  spontaneously  or  from  pres- 
voL.  II — 49 


770  SURGERY    OF   THE    KIDNEY. 

sure  or  trauma.  Such  a  possibility  should  always  be  remembered  during  palpa- 
tion. 

There  is  often  a  feeling  of  fullness  and  discomfort  in  the  tumor,  and  if  the  sac 
becomes  tense,  there  is  a  more  acute  pain,  such  as  occurs  in  overdistention  of  the 
bladder.  Frequent  micturition  and  alternating  oliguria  and  pohairia  are  noted 
in  some  cases. 

Diagnosis. — The  tumor  of  hydronephrosis  must  be  differentiated  at  times 
from  cystic  degeneration  of  the  kidney,  cystic  distention  of  the  gall-bladder,  cystic 
tumor  of  the  ovary,  and  echinococcus  cyst  of  the  liver.  It  may  also  be  resembled 
by  pyonephrosis,  solid  tumor  of  the  kidney,  and  splenic  tumor.  The  usual  relation 
of  the  colon  to  a  kidney  tumor  may  serve  to  distinguish  it  from  an  enlargement 
affecting  an  intraperitoneal  organ.  Distention  of  the  colon  with  air  will  sometimes 
be  useful  in  making  out  the  position  of  the  bowel  in  front  of  the  kidney. 

An  ovarian  cyst  is  usually  of  greater  size,  and  its  attachments  to  the  broad  liga- 
ment can  often  be  determined  by  rectal  palpation  while  the  cervix  is  pulled  down- 
ward with  a  tenaculum.  Hydatid  cysts  of  the  liver  are  directly  continuous  with 
that  organ,  usually  occupy  a  somewhat  higher  position  than  kidney  tumors,  and 
are  more  or  less  immobile. 

It  is  very  easy  to  mistake  a  cystic  gall-bladder  for  a  hydronephrotic  kidney. 
Careful  examination  will  often  suffice  to  distinguish  a  connection  between  the  liver 
and  the  tumor,  in  which  case  the  diagnosis  becomes  clear.  In  the  case  of  a  cystic 
gall-bladder,  the  enlargement  is  directly  in  relation  with  the  abdominal  wall  and 
does  not  project  in  the  loin  like  a  renal  enlargement. 

Catheterization  of  the  ureter  on  the  affected  side  w^ill  frequently  be  of  the  greatest 
aid  in  diagnosis  by  disclosing  an  obstruction  of  the  ureter.  If  the  catheter  can  be 
pushed  past  the  point  of  obstruction  into  the  hydronephrotic  sac,  the  rapid  flow 
of  fluid  and  the  diminution  in  the  size  of  the  tumor  will  be  absolutely  diagnostic. 
When  the  obstruction  is  high  up  at  the  ureteropelvic  junction,  it  is  difficult  to  pass, 
but  the  absence  of  excretion  from  this  side  in  a  completely  closed  sac  is  significant. 
A  positive  diagnosis  in  some  cases  can  only  be  made  after  an  exploratory 
incision. 

Prognosis. — The  ultimate  fate  of  a  hydronephrosis  depends  upon  the  extent 
to  which  the  kidney  has  been  damaged,  the  removability  of  the  exciting  cause, 
and  upon  the  health  of  the  opposite  kidney.  If  the  condition  has  developed  slowly 
and  the  other  kidney  has  increased  its  functional  activity,  life  may  not  be  endangered 
for  years.  This  fact  is  proved  by  cases  of  hydronephrosis  in  extreme  old  age. 
If  the  second  kidney  fails  or  if  it  too  becomes  hydronephrotic,  then  uremia  may 
rapidly  supervene.  In  six  out  of  forty-seven  cases  collected  by  "Morris  the  tumor 
disappeared  spontaneously.  Infection  of  a  hydronephrotic  sac  may  convert  it 
into  a  pyonephrosis.  Rupture  of  the  sac  may  occur  as  a  result  of  traumatism  and 
be  followed  by  hemorrhage  or  peritonitis. 

Treatment.— The  treatment  of  a  case  of  hydronephrosis  should  be  based  upon 
the  position  and  the  cause  of  the  obstruction.     It  is  evident  that  there  should  be 


HYDRO-,    URO-,    CYSTONEPHROSIS,    SAC-KIDNEY   OF   KUSTER.  771 

two  objects  in  view:  first,  removal  of  the  cause  of  obstruction;  second,  treatment 
of  the  damaged  kidney. 

Obstruction  may  be  relieved  according  to  its  cause  by  plastic  operations  on  the 
kidney  pelvis  and  ureter,  nephropexy,  removal  of  calculi,  resection  or  gradual 
dilatation  of  a  constricted  part  of  the  ureter,  prostatectomy,  removal  of  pelvic 
tumors,  urethrotomy,  etc. 

Evacuation  of  the  fluid  may  be  attempted  by  massage,  ureteral  catheterization, 
tapping,  and  nephrotomy.  Careful  replacement  of  a  displaced  hydronephrotic 
sac,  combined  with  gentle  massage,  may  be  successful  rarely  in  evacuating  the  fluid. 
In  case  the  condition  results  from  ptosis  of  the  kidney  and  kinking  of  the  ureter,  a 
re-accumulation  of  fluid  may  possibly  be  prevented  by  supporting  the  kidney  with 
a  suitable  bandage  or  binder.  In  many  cases,  however,  the  tumor  is  so  painful 
or  so  tense  that  any  efi^ort  at  replacement  or  massage  would  cause  great  suffering 
and  be  quite  dangerous.  Nephropexy  is  much  more  reliable  in  such  cases  and  is 
indicated.  Ureteral  catheterization  will  sometimes  be  successful  in  evacuating  a 
hydronephrotic  tumor. 

Tapping  has  frequently  been  used  in  the  past  as  a  means  of  relieving  distention, 
and  in  some  cases  after  repeated  tapping  the  tumor  has  disappeared.  At  the  present 
time,  however,  this  procedure  should  be  reserved  for  desperate  cases  in  which  noth- 
ing more  dare  be  attempted;  otherwise  an  exploratory  incision  and  puncture  is 
infinitely  preferable  and  may  be  done  under  local  anesthesia,  if  a  general  anesthetic 
is  undesirable.  Before  tapping  a  hydronephrotic  sac  the  colon  should  be  inflated 
so  as  to  determine  its  position  accurately.  The  needle  should  be  thrust  into  the 
sac  half-way  between  the  last  rib  and  the  crest  of  the  ilium,  on  a  line  posterior  to 
the  colon — usually  two  and  a  half  inches  back  of  the  anterior  superior  spine  of  the 
ilium. 

A  stricture  in  the  lower  part  of  the  ureter  may  be  cured  sometimes  by  the  passage 
of  graduated  ureteral  catheters  or  bougies.  With  an  improved  form  of  cystoscope 
this  is  an  easy  and  safe  procedure  and  may  be  carried  out  with  the  patient  in  the 
ordinary  dorso-sacral  posture.  It  is  preferable  to  have  the  bladder  distended 
with  boric  acid  solution  rather  than  with  air.  Preliminary  irrigation  and  the  use 
of  fluid  distention  reduces  the  danger  of  infection  from  ureteral  catheterization  to  a 
minimum.  These  statements  apply  especially  to  the  female;  ureteral  catheteriza- 
tion in  the  male  is  decidedly  more  difficult  and  will  be  of  very  limited  service  in 
the  treatment  of  hydronephrosis.  The  ureteral  instruments  must  be  passed  very 
gently  in  order  to  avoid  puncture  of  the  ureter  at  the  site  of  the  obstruction. 

Nephropexy  may  cure  cases  of  hydronephrosis  due  to  a  ptosis  of  the  kidney  and 
a  kinking  of  the  ureter.  In  relying  upon  this  method  for  a  given  case,  care  must  be 
exercised  to  make  sure  that  there  is  no  other  cause  of  obstruction.  It  will  often 
be  advisable  and  necessary  to  combine  plastic  operations  on  the  kidney  pelvis 
and  ureter  with  nephropexy,  and  in  any  case  in  which  there  is  doubt  as  to  the  cause 
of  the  obstruction,  the  kidney  pelvis  should  be  freely  opened  and  the  ureter  sounded 
from  above. 


772 


SURGERY   OF  THE  KIDNEY. 


When  the  obstruction  Kes  in  the  kidney  pelvis  or  near  the  upper  part  of  the  ureter, 
it  is  advisable  in  the  majority  of  cases  to  expose  the  kidney  by  means  of  a  lumbar 
incision  and  then  to  be  guided  as  to  further  operative  procedure  by  the  conditions 
which  are  found  in  the  individual  case. 

When  the  tumor  is  not  of  great  size  and  there  is  no  fixation  of  the  kidney,  it 
should  be  separated  carefully  from  its  surroundings  and  delivered  through  the 


mcision. 


PilC 


The  mechanics  and  the  pathologic  anatomy  of  the  individual  case  may  now  be 
determined  by  inspection  and  palpation  of  the  kidney  and  ureter  externally;  or  by 
inspection  and  probing  after  splitting  the  kidney  into  the  pelvis;  or  by  opening  the 
pelvis  itself. 

In  old  and  very  extensive  cases,  and  in  those  in  which  the  kidney  substance  is 

entirely  destroyed,  so  that  the  organ  is  useless,  im- 
mediate nephrectomy  may  be  done.     As  long,  how- 
ever,  as    the  obstructed    kidney   has   some  secreting 
tissue,  and  especially  if  the  other  kidney  is  affected 
or  its  functional  activity  is   undetermined,  nephrec- 
tomy must  not  be  considered  as  a  primary  operation. 
In  the  case  of  large  tumors  it  is 
difficult  to  detect  the  ureteral  orifice 
in  the  kidney  pelvis  or  to  palpate  the 
ureter  externally.     If  an  attempt  to 
do  so  fails,  the  best  plan  is  to  perform 
nephrotomy,  evacuate  the  fluid,  and 
drain  the  kidney  pelvis.     After  the 
sac  has  retracted,  another  operation 
may  be  undertaken,  if  required,  to 
relieve  the  obstruction  and  close  the 
fistula. 

Nephrotomy  alone  sometimes 
cures  a  hydronephrosis.  The  relief 
of  tension  in  the  sac  wall  does  away 
with  the  valvular  action  of  the 
ureteral  opening;  the  flow  of  urine  through  the  ureter  is  resumed,  and  the  fistula 
closes. 

In  seeking  the  cause  of  the  obstruction,  great  difficulty  will  often  be  experienced 
in  locating  the  ureteral  orifice  in  tlie  kidney  pelvis.  The  attempt  should  not  be 
prolonged;  instead,  the  original  lumbar  incision  should  be  lengthened,  the  ureter 
exposed  and  opened  below,  and  a  sound  passed  through  it  upward  into  the  kidney 
pelvis. 

If  the  obstruction  is  found  at  the  junction  of  the  ureter  and  pelvis,  the  valve 
formation  may  be  cured  by  incising  it  longitudinally  and  bringing  the  margins  of 
the  incision  together  in  a  transverse  direction  (Fig.  843). 


Fig.  842. — Israel's  Operation  of  Pteloplication. 
Observe  how  the  ureter  is  carried  up  oq  the  surface  of 
the  distended  pelvis,  and  the  kink  at  the  uretero-pelvic 
junction.  /,  Shows  sewed-up  incision  in  posterior  wall  of 
pelvis;  S,  sutures  for  pyeloplication;  Su,  suture  for  correc- 
tion of  ureter;    U,  ureter. 


HYDRO-,   URO-,    CYSTONEPHROSIS,    SAC-KIDNEY   OF   KUSTER. 


773 


When  the  configuration  of  the  sac  is  such  that  the  ureteral  orifice  is  high  up, 
the  angle  between  the  sac  and  the  ureter  may  be  lessened,  and  a  lower  position 
may  be  secured  for  the  latter  by  excising  a  portion  of  the  sac  wall  or  by  adopting 
Israel's'  plan  of  pyeloplication  (Fig.  842).  Kiister  has  overcome  these  difficulties 
by  excising  the  upper  end  of  the  ureter  and  implanting  it  into  the  pelvis  lower  down. 
This  would  be  especially  desirable  when  the  upper  end  of  the  ureter  is  the  seat  of  a 
stricture. 


Fig.  843. — Israel's  Plan  fob  the  Correction  of  a  False  Valve  at  the  Junction  of  the  Kidney  Pelvis 

AND  THE  Ureter. 
P,  Pelvis  of  kidney;  V,  valve  of  ureter;  S,  sutures. 


When  hydronephrosis  is  due  to  kidney  or  ureteral  stone,  its  treatment  becomes 
that  of  nephrolithiasis.  After  removing  the  calculus  from  the  kidney  or  the  ureter 
as  the  case  may  be,  a  careful  investigation  should  be  made  in  order  to  determine 
whether  the  obstruction  has  been  entirely  overcome.  When  it  is  certain  that  no 
calculi  still  remain  in  the  kidney  or  ureter,  the  course  of  procedure  depends  on  the 
*  Israel,  Jas.:     "Chirurgische  Klinik  der  Nierenkrankheiten,"  Berlin,  1901. 


774  SURGERY  OF  THE  KIDNEY. 

degree  to  which  the  kidney  has  been  damaged.  Because  of  the  tendency  of  both 
kidneys  to  be  affected  in  nephroHthiasis,  nephrectomy  should  not  be  considered 
as  a  primary  operation.  In  certain  cases  even  after  the  removal  of  the  calculi, 
when  obstruction  is  absolute  from  ulcerative  and  cicatricial  changes  and  the  oppo- 
site kidney  is  healthy  and  has  been  performing  the  work  of  both  organs  satisfactorily 
for  some  time,  nephrectomy  may  be  indicated.  As  a  rule,  in  such  cases  the  hydro- 
nephrosis has  become  a  pyonephrosis.  Drainage  should  be  used  if  the  case  is 
septic  or  there  is  still  some  obstruction.  The  reader  is  referred  to  the  sections  on 
the  treatment  of  kidney  stone  and  the  operations  of  nephrotomy  and  nephrolith- 
otomy. 

If  the  cause  of  obstruction  in  a  case  of  hydronephrosis  is  found  to  be  in  the  ureter 
at  some  distance  from  the  kidney,  the  latter  should  be  approached  retroperitoneally. 
(See  Chapter  XL VIII  for  plans  of  treatment.) 

When  the  kidney  is  sacculated  in  a  case  of  hydronephrosis  and  instead  of  one 
large  cavity  there  are  a  number  of  smaller  ones  communicating  by  narrow  necks 
with  the  kidney  pelvis,  the  plan  of  operation  should  be  that  of  Fenger.  After 
nephrotomy  the  partition  walls  between  the  smaller  sacs  are  divided  so  that  all 
parts  of  the  cystic  kidney  communicate  with  each  other.  Hemorrhage  is  controlled 
by  digital  pressure,  the  cautery,  sutures,  and  gauze  tampons.  Drainage  is  main- 
tained until  any  subacute  inflammatory  process  in  the  kidney  has  subsided,  and 
until  obstruction  to  the  ureter  has  been  overcome  either  by  a  plastic  operation  or 
by  repeated  soundings.  The  two  halves  of  the  kidney  may  then  be  freed  from 
adhesions  and  reunited. 

NON-TUBERCULOUS  INFLAMMATORY  LESIONS  OF  THE  KIDNEY— PYELONEPH- 
RITIS, PYONEPHROSIS,  EMPYEMA  OF  THE  KIDNEY  PELVIS,  AND 
KIDNEY  ABSCESS. 

An  infection  may  reach  the  kidney:  either  (1)  through  the  blood — descending 
or  hematogenous  infection;  or  (2)  from  some  point  in  the  urinary  passages — 
ascending  infection;  or  (3)  it  may  come  from  the  direct  extension  of  an  infection 
from  a  neighboring  organ,  as,  for  example,  an  appendicitis,  a  vertebral  caries,  or 
an  abscess  of  the  liver  or  the  spleen.  Infection  of  the  kidney  through  the  blood 
may  follow  whenever  bacteriemia  occurs  in  such  diseases  as  pneumonia,  typhoid 
fever,  diphtheria,  osteomyelitis,  puerperal  sepsis,  erysipelas,  phlegmons,  furuncles, 
infected  wounds,  etc. 

An  ascending  infection  from  some  point  in  the  urinary  tract  may  occur  through 
the  lymphatics  and  the  veins  in  wounds,  inflammations,  and  ulcerations  along  the 
course  of  the  ureter.  Ascending  invasion  usually  is  taken  to  mean  an  extension 
of  infection  from  the  bladder  along  the  mucous  membrane  of  the  ureter  to  the  kidney 
pelvis. 

The  organisms  which  take  an  active  part  in  suppurative  diseases  of  the  kidney 
are  the  streptococcus  pyogenes  aureus,  the  staphylococcus  pyogenes  aureus,  the  pro- 
teus  vulgaris,  the  bacterium  coli  commune,  and  the  gonococcus. 


PYELONEPHRITIS.  775 

The  streptococcus  is  the  organism  most  often  concerned  in  a  descending  or 
hematogenous  infection.  The  staphylococcus  and  the  gonococcus  may  also  reach 
the  kidney  through  the  blood.  As  already  indicated,  the  pneinnococcus,  the  bacillus 
typhosus,  and  others,  cause  hematogenous  infection  of  the  kidney. 

The  organisms  most  apt  to  produce  ascending  infection  are  those  which  cause 
decomposition  of  the  urine  and  are  motile.  Of  these,  the  bacterium  coli  commune 
is  by  far  the  most  frequent.  According  to  Kiister,  in  about  two-thirds  of  all  cases 
of  infection  it  occurs  either  in  pure  culture  or  mixed  with  other  bacterial  forms. 
The  organism  is  slightly  motile.  Urine  containing  the  bacillus  in  pure  culture  is 
offensive,  has  a  peculiar  opalescent  appearance,  and  possesses,  without  exception, 
an  acid  reaction,  which  it  retains  for  days. 

The  proteus  vulgaris  quickly  makes  the  urine  alkaline;  because  of  its  motility 
and  rapid  growth  it  easily  gains  access  to  the  kidney  pelvis.  Urine  containing  this 
organism  has  a  disgustingly  foul  odor.  Whether  it  is  the  primary  cause  in  all 
cases  in  which  it  is  found  in  pure  culture  is  questionable;  by  its  quickness  in  growth 
it  may  supplant  the  primary  organism. 

Gonococcus  infections  of  the  urethra  and  bladder  are  so  common  that  one  would 
suppose  gonococcus  infection  of  the  upper  urinary  passages  to  be  frequent.  The 
gonococcus,  however,  has  not  often  been  recognized  in  cultures  taken  from  the 
pelvis  of  the  kidney  or  the  upper  ureter.  In  the  course  of  ascending  infections  of  the 
urinary  tract,  apparently  due  to  the  gonococcus,  fermentation  and  decomposition  of 
the  urine  are  frequent,  and  as  the  gonococcus  never  causes  decomposition  of  the  urine, 
this  fact  would  seem  to  indicate  that  it  alone  is  not  the  cause  of  such  infections. 
According  to  Kiister,  the  possibility  of  an  ascending  infection  by  the  gonococcus 
is  very  slight,  while  the  possibility  of  its  metastatic  deposit  in  the  kidney  cannot  be 
doubted.  The  chief  role  played  by  the  gonococcus  is  undoubtedly  found  in  the 
alterations  favorable  to  the  growth  of  other  bacteria  which  it  produces  in  the  lower 
urinary  passages.  For  example,  stricture  results  in  a  stasis  of  the  urine  favoring 
the  growth  of  other  organisms  and  their  ascension  of  the  ureter  by  their  own 
motility  or  by  reflex  peristalsis. 

The  staphylococcus  pyogenes  aureus  is  frequently  found  in  the  bladder,  but 
seldom  in  a  kidney  abscess,  and  then  only  from  infection  through  the  blood.  The 
urine  when  it  contains  this  organism  is  commonly  alkaline,  or  at  least  neutral. 
The  streptococcus  pyogenes  is  commonly  associated  with  severe  general  symptoms 
and  metastatic  pyemic  abscesses.  Infection  usually  occurs  by  the  blood,  but 
ascending  infection  is  possible.  The  pure  culture  is  not  so  often  found  as  in  the 
case  of  the  staphylococcus;   when  it  occurs  in  pure  culture,  the  urine  is  acid. 

The  mere  presence  of  bacteria  in  the  lower  urinary  passage  is  not  all  that  is 
requisite  for  an  ascending  infection.  Added  to  this  usually  there  is  a  stasis  of  the 
urine  in  the  ureter  or  bladder.  This  obstruction  to  the  urinary  outflow  may  be 
found  in  strictures  or  in  sacculations  of  the  ureter,  bladder,  or  urethra.  The  most 
frequent  cause  in  young  men  is  a  gonorrheal  stricture;  in  old  men,  an  enlarged 
prostate;  in  women,  a  kinked  ureter  associated  with  floating  kidney,  or  a  compressed 


776  SURGERY  OF  THE  KIDNEY. 

ureter  associated  with  pregnancy  or  a  tumor.  Instrumentation  in  such  cases  fre- 
quently leads  to  slight  abrasions  of  the  mucosa,  which  favor  bacterial  invasion. 
The  virulence  of  the  particular  organism  and  the  resistance  of  the  individual  are 
factors  of  much  importance  in  the  pathogenesis  of  both  ascending  and  descending 
infections. 

Pathologic  Anatomy. — The  kidneys  often  give  evidence  of  a  previous  cirrhosis. 

The  descending  hematogenous  form  of  pyelonephritis  is  usually  bilateral.  In  the 
severest  form  death  occurs  in  a  few  hours,  and  the  only  changes  which  occur  are 
congestion  and  some  ecchymosis  beneath  the  capsule.  In  cases  of  slightly  longer 
duration  marked  hemorrhages  occur  throughout  the  kidney.  In  less  acute  forms 
minute  abscesses  are  found  scattered  through  the  cortex  of  the  kidney.  They 
may  appear  like  fine  dots  arranged  in  rows  in  the  form  of  a  wedge  with  its  base 
toward  the  fibrous  capsule.  The  surrounding  and  intervening  tissue  is  infiltrated 
with  blood.  The  epithelium  of  the  cortical  tubules  undergoes  degeneration.  At  a 
later  stage  abscesses  are  found  throughout  the  cortex,  even  so  near  the  surface  that 
they  cause  the  capsule  to  bulge;  sometimes  they  break  through  into  the  perinephric 
tissue.  The  medullary  part  of  the  kidney  next  becomes  involved.  Individual 
abscesses  form,  coalesce  with  others,  and  finally  the  kidney  is  honeycombed  with 
abscess  cavities  having  inflamed  and  degenerated  kidney  parenchyma  between 
them.     The  pus  finally  breaks  into  the  kidney  pelvis. 

Pyelitis  ensues  and  the  ureter  becomes  obstructed  either  by  the  congestion  and 
swelling  of  the  mucous  membrane,  as  already  noted  (p.  766),  or  by  masses  of  broken- 
down  kidney  tissue,  or  by  actual  inflammatory  and  cicatricial  processes  at  the  mouth 
of  the  ureter  or  in  its  upper  part.  The  kidney  pelvis  distends  with  urine  and  pus, 
and  this  increase  of  tension  favors  the  destruction  of  the  septa  between  the  abscess 
cavities  in  the  kidney  substance,  so  that  the  entire  structure  may  become  converted 
into  a  single  pus  sac. 

In  ascending  pyelonephritis  alterations  are  usually  found  in  the  bladder  and 
ureter.  The  mucous  membrane  of  each  in  mild  cases  exhibits  a  vivid  red  color; 
it  is  swollen,  somewhat  loosened  from  the  underlying  tissue,  and  covered  with 
muco-pus.  In  the  severer  forms  the  mucosa  has  a  dark  red  color  and  here  and 
there  exhibits  patches  of  ulceration.  The  ureters  may  show  alternate  dilatation  and 
contraction,  or  they  may  be  fixed  by  inflammatory  deposits  about  them.  In  some 
cases  the  alterations  in  the  ureter  are  insignificant.  The  mucosa  of  the  kidney 
pelvis  is  injected,  swollen,  and  thrown  into  folds.  In  severe  forms  it  may  be  dark 
red  in  color  and  covered  here  and  there  by  adherent  yellow  membrane.  In  the 
severest  forms  the  mucosa  becomes  necrotic. 

If  there  is  no  obstruction  to  the  urinary  outflow,  the  pelvis  is  slightly  distended 
with  cloudy,  purulent,  and  foul-smelling  urine,  sometimes  containing  necrotic 
epithelium.  Hemorrhagic  areas  in  the  mucosa  may  be  seen  if  calculi  are  present. 
When  the  urine  is  ammoniacal,  granules  of  the  phosphate  of  lime  may  be  found 
embedded  in  the  mucosa.  When  the  latter  is  necrotic,  the  papilla  simply  may  be 
covered  with  the  necrotic  membrane  or  they  themselves  may  become  involved 


PYELONEPHRITIS. 


777 


and  slough  off.  The  involvement  of  the  kidney  tissue  occurs,  as  a  rule,  first  in  the 
medullary  part  of  the  organ.  The  path  of  the  infection  is  shown  by  red  stripes 
running  from  the  pelvis  to  the  capsule,  along  which  rows  of  abscesses  quickly  arise 
and  may  appear  on  the  surface  of  the  kidney  as  thickly  scattered  elevated  points. 
These  abscesses  increase  in  size  and  coalesce  until  the  kidney  is  honeycombed 
with  them. 

There  is  usually  stagnation  of  urine  at  this  time  and  some  dilatation  of  the  kid- 


Aiihcess 


Fig.  844. — Calculus  Pyonephrosis. 
The  distention  of  the  kidney  pelvis,  the  destruction  of  the  kidney  substance,  and  the  adhesions  of  the  surrounding 

fatty  tissue  are  to  be  noted.     (Natural  size.) 

ney  pelvis  secondary  to  the  changes  occurring  in  the  mucosa  of  the  pelvis  which 
more  or  less  completely  block  the  ureter.  The  back  pressure  of  the  urine  increases 
the  tension  within  the  kidney  and  favors  the  coalescence  of  abscess  cavities  with 
each  other  and  with  the  kidney  pelvis.  In  this  way  the  organ  may  be  converted 
into  a  large  abscess  sac  with  very  little  kidney  tissue  remaining. 

There  may  be  many  variations  in  the  cour.se  of  the  infection  as  it  has  been 
described.     The  process  may  be  limited  to  the  pelvis  and  never  extend  to  the  true 


778  SURGERY    OF   THE    KIDNEY. 

kidney  substance.  There  are  fewer  changes  in  the  kidney  from  pressure  than  in 
cases  of  hydronephrosis.  When  the  evidences  of  pressure  are  marked,  the  lesion 
may  have  resulted  from  the  infection  of  a  previous  hydronephrosis. 

In  case  the  pus  from  the  kidney  is  entirely  evacuated  into  the  paranephric  tissue, 
the  organ  may  shrink  and  form  a  dense  cicatrix,  which  has  a  cartilaginous  or  even 
a  bony  hardness.  When  the  evacuation  is  but  partial,  an  indurated  and  adherent 
fatty  capsule  may  surround  the  eroded  organ  on  all  sides.  In  rare  cases  the  abscess 
is  not  evacuated;  the  fluid  of  the  pus  is  absorbed,  and  the  remainder  becomes 
thick  and  forms  a  yellow  caseous  substance  packed  into  the  irregular  cavities  within 
the  kidney  shell,  the  process  thus  resembling  tuberculosis  of  the  kidney. 

Symptoms. — Acute  hematogenous  suppuration  of  the  kidney,  when  it  occurs 
in  the  course  of  a  general  bacteriemia,  may  be  so  rapidly  fatal  that  there  are  no 
symptoms  pointing  directly  to  the  kidneys,  the  indications  of  the  kidney  lesion  being 
masked  by  the  general  symptoms. 

Less  violent  forms  are  usually  preceded  by  some  general  infection,  such  as 
typhoid,  pneumonia,  erysipelas,  puerperal  sepsis,  etc.  The  patient  suffers  with  a 
chill,  dyspnea,  cyanosis,  high  fever,  and  great  prostration.  The  sensibilities  may 
be  clouded  and  there  may  be  involuntary  evacuation  of  the  bowels.  Sometimes 
there  is  violent  pain  in  the  loins,  associated  with  oliguria  or  anuria.  Blood  and 
hyaline  casts  may  be  found  in  the  urine.  The  kidney  region  may  be  sensitive  to 
pressure,  but  no  recognizable  enlargement  of  the  organ  is  present  at  first.  Leukocy- 
tosis is  present,  varying  in  degree  according  to  the  severity  of  the  infection  and  the 
resistance  of  the  individual. 

After  suppuration  in  the  kidney  is  established,  the  fever  becomes  remittent 
and  is  broken  by  chills.  The  patient  enters  a  low  typhoidal  state  and  there  may  be 
symptoms  of  uremia. 

The  urine  contains  granular  casts,  pus,  and  albumin;  the  latter  is  excessive 
in  proportion  to  the  amount  of  pus.  There  may  be  no  other  alteration  in  the  urine 
except  a  diminution  in  the  total  amount.  A  sudden  increase  in  the  amount  of  pus 
in  the  urine  indicates  the  evacuation  of  an  abscess  into  the  kidney  pelvis. 

Death  may  occur  from  a  combination  of  septic  intoxication  and  uremia  or  from 
exhaustion.  Or  the  disease  may  become  chronic;  a  change  to  the  chronic  form 
being  associated  with  an  increased  pyuria  and  an  improvement  in  the  general  con- 
dition. Leukocytosis  may  disappear  if  the  foci  of  suppuration  in  the  kidney  are 
draining  freely  through  the  ureter. 

Ascending  pyelonephritis  is  usuarlly  preceded  by  some  lesion  of  the  lower  urinary 
organs;  gonorrheal  stricture  is  the  most  frequent;  others  are  enlarged  prostate, 
new-growths  of  the  bladder,  and  new-growths  or  inflammatory  lesions  of  the 
parametrium.  Very  often  the  attack  is  preceded  by  bacteriuria  for  a  longer  or 
shorter  time.  This  may  cause  a  patient  no  inconvenience  except  from  the  dis- 
gusting odor.  The  attention  of  the  patient  may  be  attracted  also  by  the  cloudi- 
ness of  the  urine.  On  examination  the  urine  is  acid  and  contains  epithelial  cells, 
leukocytes,  and  myriads  of  bacteria. 


SYMPTOMS    OF   ASCENDING    PYELONEPHRITIS.  779 

Cystitis  may  precede  the  kidney  infection,  or  the  bladder  may  remain  compara- 
tively healthy.  Not  infrequently  the  attack  is  precipitated  by  instrumentation  of 
the  urethra,  bladder,  or  ureter.  Sooner  or  later  pyuria  and  pain  along  the  ureter 
of  the  affected  side  occur.  If  the  ureter  is  palpated  through  the  vagina  or  the 
rectum,  it  may  be  found  hard,  thick,  and  tender.  Dull  pain  and  tenderness  in  the 
lumbar  region  or  sharp  stabbing  pain  radiating  along  the  ureter  may  be  present. 
The  urine  contains  increasing  amounts  of  pus. 

Disturbance  of  the  general  health  occurs,  but  is  less  pronounced  when  the  urine 
remains  acid.  There  is  anorexia,  coated  tongue,  and  slight  fever  of  a  remittent  or 
paroxysmal  form. 

If  the  urine  becomes  alkaline  early,  the  general  symptoms  are  more  marked. 
Alkalinity  is  usually  associated  with  severe  cystitis.  There  may  be  diarrhea  alter- 
nating with  constipation.  Anemia  and  emaciation  occur.  Leukocytosis  is  present 
if  there  is  any  accumulation  of  pus.  There  is  clouding  of  the  sensibilities  and 
swelling  of  the  feet  and  ankles;  not  infrequently  an  unpleasant  odor  of  decomposing 
urine  is  observed  on  the  breath  and  about  the  entire  body. 

The  clinical  picture  may  be  modified.  There  may  be  severe  renal  colic  asso- 
ciated with  high  fever  and  leukocytosis,  the  symptoms  diminishing  after  a  time 
coincidently  with  a  profuse  discharge  of  pus  in  the  urine.  These  attacks  may  be 
repeated  until  the  patient  is  comfortable  only  when  a  considerable  amount  of  pus 
is  being  passed  in  the  urine.  Attacks  of  sharp  pain  associated  with  diminished 
pyuria  and  increased  pyrexia  are  due  to  obstruction.  These  symptoms  are  relieved 
when  the  pressure  of  the  pent-up  urine  and  pus  overcomes  the  obstruction. 

The  affected  kidney  or  kidneys  gradually  increase  in  size,  the  enlargement 
diminishing  at  times  after  the  passage  of  a  large  quantity  of  pus. 

In  pyelonephritis  which  follows  disease  of  the  neighboring  organs,  attention 
will  hardly  be  drawn  to  the  kidney  until  vesical  irritation,  pyuria,  or  lumbar  pain 
make  their  appearance.  When  suppuration  occurs  in  an  injured  kidney,  the 
symptoms  of  the  trauma  will  be  replaced  by  those  of  inflammation. 

Diagnosis. — The  severest  form  of  hematogenous  ptjelonephritis  is  usually 
masked  by  the  symptoms  of  a  general  bacteriemia.  If  in  the  course  of,  or  shortly 
following,  typhoid,  pneumonia,  or  wound  infection,  there  is  a  sudden  chill  followed 
by  a  rise  of  temperature,  semi-consciousness,  and  stupor,  a  kidney  lesion  may  be 
suspected.  If  oliguria  or  anuria  is  present,  if  casts  and  blood  are  found  in  the  urine, 
and  if  there  is  any  renal  pain,  the  diagnosis  is  nearly  certain. 

In  the  less  severe  and  the  more  chronic  forms,  local  pain,  tenderness,  and  slight 
enlargement  will  indicate  a  kidney  lesion,  and  a  careful  examination  of  the  urine 
and  of  the  lower  urinary  organs  for  evidences  of  suppuration  and  obstruction  will 
assist  in  the  diagnosis.  Occasionally  pyuria  for  a  long  time  may  be  the  only  local 
symptom  of  kidney  suppuration. 

In  the  course  of  a  suppurative  lesion  ascending  from  the  bladder  to  the  kidney, 
there  is  some  difficulty  often  in  determining  whether  one  or  both  kidneys  are  affected. 


780  SURGERY  OF  THE  KIDNEY. 

Moreover,  it  is  possible  for  the  symptoms  of  pyelonephritis  to  be  masked  by  those 
of  cystitis,  or  a  cystitis  may  simulate  a  beginning  pyelonephritis. 

It  is  easy  enough  to  determine  an  involvement  of  the  kidney  when  that  organ 
is  enlarged  and  tender,  but  there  is  some  difficulty  in  finding  out  whether  the  lesion 
is  confined  to  the  pelvis  or  has  affected  both  the  pelvis  and  the  kidney  substance. 
The  presence  of  casts  may  be  serviceable  in  making  a  distinction.  If  the  enlarge- 
ment of  the  kidney  is  intermittent  and  a  diminution  in  size  is  followed  by  the  discharge 
of  a  considerable  amount  of  pus  in  the  urine,  a  pyonephrosis  is  evident.  There 
are  certain  cases,  however,  in  which  the  diagnosis  will  necessarily  depend  upon  a 
careful  examination  of  the  bladder,  ureteral  orifices,  and  urine. 

Upon  cystoscopic  examination,  in  most  cases  of  suppurative  inflammation  of 
the  kidney,  lesions  will  be  seen  at  the  site  of  the  corresponding  ureteral  orifice. 
Sometimes,  however,  this  sign  is  totally  wanting.  Garceau^  reported  a  case  of 
suppurating  kidney  in  w-hich  the  corresponding  ureteral  eminence  and  the  bladder 
were  not  at  all  diseased.  It  is  unwise  to  catheterize  the  ureters  if  the  bladder  is 
infected  and  the  question  of  ureteral  involvement  is  in  doubt.  Under  such  circum- 
stances the  separate  urines  may  be  collected  by  the  Harris  segregator,  or  the 
excretion  may  be  collected  directly  from  the  ureteral  orifice  through  a  Kelly 
cystoscope.  If  the  bladder  is  washed  out  thoroughly  and  the  urine  as  it  collects 
from  the  ureters  is  immediately  examined,  a  fair  idea  of  the  kidney  excretion  may 
be  obtained.  If  pus  is  coming  from  the  kidney,  it  will  be  noticed  in  the  urine  at 
once;  while  if  it  comes  from  the  bladder  lesion,  a  little  time  must  elapse  after  the 
irrigation  before  it  appears  to  any  extent  in  the  urine. 

The  bladder  itself  need  not  show  a  lesion,  although  it  usually  does.  This  is 
either  antecedent  or  subsequent  to  the  renal  involvement.  If  the  bladder  is  clean 
and  neither  the  state  of  the  ureteral  orifices  nor  the  symptoms  sufficiently  indicate 
the  exact  position  of  the  lesion,  catheterization  of  the  ureters  will  show  the  condition 
of  each  kidney. 

The  constituents  of  the  urine  and  their  amount  may  indicate  to  a  certain  extent 
the  parts  involved.  Granular,  blood,  or  pus  casts  indicate  kidney  involvement; 
a  diminished  excretion  of  urea  has  the  same  significance.  Practically  no  exact 
differentiation  can  be  made  between  the  epithelium  of  the  kidney  and  that  of  the 
bladder. 

The  amount  of  albumin  is  usually  increased  disproportionately  to  the  amount 
of  pus,  when  the  kidney  is  involved.  According  to  Kiister,  if  the  bladder  alone  is 
affected,  the  amount  of  albumin  is  rarely  more  than  0.1  per  cent.;  at  most  not 
above  0.15  per  cent.     In  pyelonephritis  it  rises  to  two  or  three  times  that  amount. 

If  the  urine  is  alkaline,  albuminous  products  will  be  caused  by  disintegration 
of  the  pus  corpuscles  or  from  the  action  of  the  bacteria  upon  the  peptones.  Accord- 
ing to  Schede,  the  quantitative  test  for  albumin  must  be  controlled  by  an  estima- 
tion of   the  leukocytes  in  the  urine;  50,000  to  70,000  pus  cells  per  cubic  millimeter 

^Garceau,  Edgar:  "Vesical  Appearances  in  Renal  Suppuration,"  Boston  Med.  and  Surg. 
Jour.,  1903,  cxlviii,  No.  3,  pp.  57-59. 


PYELONEPHRITIS.  781^ 

is  equivalent  to  1  part  of  albumin  per  1000  by  the  Esbach  test.  Red  blood-cor- 
puscles are  more  indicative  of  stone  or  tuberculosis  than  of  pure  pyelonephritis. 
Nucleo-al})umin  in  large  amount  indicates  pyelitis  rather  than  nephritis. 

The  total  excretion  of  urine  has  some  significance.  When  an  infection  is  con- 
fined to  the  kidney  pelvis  and  in  the  early  stages  of  pyelonephritis  of  the  ascending 
form,  polyuria  is  quite  constant.  In  cases  of  intermittent  obstruction  to  the  ureteral 
outflow  oliguria  may  alternate  with  polyuria.  If  there  is  permanent  obstruction 
of  the  ureter,  the  urine  may  be  normal  in  amount  or  there  may  be  polyuria;  the 
latter  is  due  to  excessive  activity  of  the  other  kidney.  The  quantity  of  urine 
excreted  by  a  kidney  the  seat  of  a  suppurative  process  may  be  increased  at  first  on 
account  of  congestion.  When  actual  destruction  of  the  parenchyma  begins,  there 
is  a  diminution  or  a  cessation  of  the  excretion  from  the  affected  area,  although  the 
remaining  uninvolved  parts  of  the  organ  may  act  in  a  compensatory  way  for  a  time. 

Prognosis. — The  prognosis  of  suppurative  pyelonephritis  is  grave.  In  the 
severest  forms  death  occurs  in  from  twenty-four  to  seventy-two  hours.  Most 
patients  perish  in  from  two  to  three  weeks.  Kiister  reports  one  hundred  and  forty- 
two  deaths  in  three  hundred  and  twenty-eight  cases  of  pyelonephritis  associated 
with  bacteriuria  (43.29  per  cent.).  Favorable  factors  in  the  particular  case  are: 
Limitation  of  the  disease  to  the  kidney  pelvis;  a  source  of  obstruction  easy  to 
overcome;  a  unilateral  affection;  youth  and  an  otherwise  healthy  body. 

Treatment. — In  the  descending  or  hematogenous  form  of  pyelonephritis  treat- 
ment at  first  must  be  directed  toward  the  lesion  to  which  the  kidney  infection  is 
secondary.  Any  primary^  foci  of  infection  which  can  be  eradicated  should  receive 
immediate  attention,  while  at  the  same  time  the  patient  is  supported  by  such 
general  measures  as  are  indicated  in  bacteriemia  and  septicemia.  Attention  should 
then  be  given  to  the  kidney,  over  which  dry  cups  and  applications  of  ice  may  be 
used.  As  soon  as  there  is  palpable  enlargement  of  the  organ  and  the  evidences  of 
suppuration  therein  are  definitely  established,  operation  may  be  considered.  If 
the  general  condition  of  the  patient  permits,  the  kidney  should  be  exposed  in  the 
loin,  the  pus  should  be  evacuated  through  the  ordinary  nephrotomy  incision  and 
efficient  drainage  provided. 

In  a  mild  ascending  infectioji  where  the  disease  is  probably  limited  to  the  kidney 
pelvis  there  are  two  indications:  First,  to  relieve  any  obstruction  which  may 
exist;  and  second,  to  increase  the  amount  of  urine  and  render  it  as  bland  as  possible. 

It  may  be  evident  from  the  first  that  a  serious  degree  of  obstruction  is  present. 
An  immediate  operation  may  be  required  if  there  is  a  stone  blocking  the  ureter,  a 
high  ureteral  stricture,  or  a  violent  ulcerative  cystitis.  In  some  cases  dilatation  of 
the  urethra,  permanent  urethral  catheterization,  or  repeated  catheterization  and 
irrigation  of  the  bladder  will  suffice  to  prevent  retention  and  place  the  lower  urinary 
organs  in  the  most  favorable  condition. 

In  pyelitis  caused  by  ureteral  stricture  catheterization  of  the  ureter  and  irriga- 
tion of  the  kidney  pelvis  with  warm  boric  acid  solution  until  the  fluid  returns  clear 
may  be  curative.     Following  the  irrigation  with  boric  acid,  silver  nitrate  1  to  3 


782  SURGERY  OF  THE  KIDNEY. 

parts  to  1000  may  be  tried.  All  local  measures  must  be  employed  with  the  greatest 
gentleness  and  the  most  rigid  asepsis. 

The  urinary  antiseptics  and  diluents  employed  should  depend  upon  the  reaction 
of  the  urine.  If  the  urine  is  acid,  salol,  grs.  v  to  x,  may  be  given  every  three  hours 
with  a  full  glass  of  water.  Jn  case  the  urine  is  alkaline,  benzoic  acid  and  urotropin 
(grs.  V  to  X  every  three  hours)  should  be  administered.  Aside  from  these  measures, 
the  patient  should  be  put  to  bed  and  a  skim  milk  diet  should  be  prescribed.  If 
there  is  pain  in  the  lumbar  region,  dry  cups  followed  by  hot  fomentations  should 
be  used.  Hypodermic  injections  of  morphin  may  be  required.  If  uremia  super- 
venes, hot  packs  with  hypodermoclysis  and  rectal  enemata  of  salt  solution  are 
indicated. 

If  the  symptoms  become  progressively  worse,  so  that  retention  of  pus  within 
the  kidney  pelvis  or  an  extension  of  the  suppurative  process  to  the  body  of  the 
organ  is  suspected,  immediate  surgical  intervention  is  indicated.  Unless  this  is 
done  promptly,  widespread  destruction  of  the  kidney  may  occur.  If  after  exposing 
the  kidney  it  appears  certain  that  the  suppuration  is  entirely  confined  to  the  pelvis, 
an  incision  into  the  posterior  wall  of  the  latter  may  suffice.  The  margins  of  the 
pelvic  incision  should  be  stitched  to  the  borders  of  the  wound  and  efficient  drainage 
provided.  If  the  process  has  extended  to  the  medulla  or  the  cortex  of  the  kidney,  a 
nephrotomy  incision  should  be  made  along  Brodel's  white  line  and  the  pelvis  and 
calyces  exposed  to  thorough  examination.  All  collections  of  pus  should  be  evac- 
uated and  abundant  drainage  provided.  No  extensive  search  should  be  made  at 
this  time  for  an  obstruction,  and  no  attempt  to  treat  one  surgically  should  be  made, 
unless  it  is  very  apparent  and  easy  to  remove,  as,  for  example,  in  the  case  of  some 
calculi. 

In  well-marked  cases  of  pyonephrosis  nephrectomy  may  be  done  at  once  if  the 
kidney  is  hopelessly  destroyed  and  the  excretory  activity  of  the  other  kidney  is 
known  to  be  good.  Even  in  very  advanced  cases,  however,  if  the  function  of  the 
other  kidney  is  a  matter  of  doubt,  primary  nephrectomy  is  absolutely  contraindi- 
cated.  It  is  remarkable  that  apparently  useless  kidneys  have  been  restored  to 
function  by  nephrotomy,  and  that  the  removal  of  such  an  organ  has  led  to  the  dis- 
covery that  it  was  the  only  kidney  or  the  better  one  the  patient  possessed. 

There  is  a  form  of  hydronephrosis  complicated  by  pyelonephritis  in  which  a 
moderately  distended  pelvis  communicates  with  multiple  dilated  calyces;  this  is 
spoken  of  by  Fenger  as  a  "sacculated"  kidney.  He  believes  that  the  condition 
occurs  in  cases  of  hydronephrosis  which  have  been  infected  early,  and  the  inflam- 
matory process  has  resulted  in  a  thickening  of  the  submucosa  and  a  retraction 
or,  at  least,  a  resistance  against  dilatation  of  the  tissues. 

The  best  operative  treatment  for  sacculated  kidney  is  to  perform  nephrotomy 
and  divide  the  partition  walls  so  that  there  is  free  communication  between  all 
parts  of  the  kidney  sac.  Hemorrhage  is  controlled  by  digital  pressure,  the  cautery, 
sutures,  and  gauze  tamponade.  After  drainage  has  reduced  the  inflammatory 
trouble  and  the  obstruction  to  the  ureter  has  been  overcome,  either  by  repeated 


TUBERCULOSIS    OF   THE   KIDNEY. 


783 


sounding  from  above  or  by  a  plastic  operation,  the  two  halves  of  the  bisected 
kidney  should  be  released  from  adhesions  and  united.  In  this  way  Fenger  has 
restored  such  an  organ  to  functional  activity. 


TUBERCULOSIS  OF  THE  KIDNEY. 

Frequency. — Walker^  found  seven  hundred  and  eighty-four  tuberculous  sub- 
jects in  1369  autopsies.  There  were  kidney  lesions  in  sixty-one.  In  thirty-six 
cases  of  miliary  tuberculosis  the  kidneys  were 
affected  every  time.  The  rather  high  propor- 
tion of  tuberculous  cases  at  the  Johns  Hopkins 
Hospital,  Walker  believes  is  explained  by  the 
fact  that  a  routine  microscopic  examination  of 
all  organs  was  made.  The  liver  and  the  spleen 
were  involved  just  about  as  often  as  the  kidney. 
Morris  records  that  there  were  seventy-four 
cases  of  renal  tuberculosis  observed  in  3331 
autopsies  at  the  Middlesex  Hospital,  and  in 
but  ten  of  the  seventy-four  was  the  disease  con- 
fined to  the  kidney. 

Walker  could  not  demonstrate  a  single  case 
of  primary  tuberculosis  of  the  kidney,  although 
in  six  instances  the  process  seems  to  have  started 
in  some  part  of  the  genito-urinary  tract.  As 
Morris  remarks,  however,  "  the  multiple  condi- 
tions found  at  death  do  not  prove  that  the  tu- 
berculous disease  was  not  for  a  time  limited  to 
one  kidney,  and  that  from  this  source  the  dis- 
ease was  disseminated  to  the  other  organs  or 
parts."  That  primary  tuberculosis  of  the  kid- 
ney does  occur  is  proved-  by  the  case  (autopsy) 
recorded  by  Stewart  and  Kelly .^ 

Age  and  Sex. — The  disease  is  uncommon  in 
the  young  except  as  a  part  of  general  tubercu- 
losis. The  average  age  of  patients  suffering 
from  renal  tuberculosis  is  thirty-two  and  a  half 
years.^  It  occurs  a  little  oftener  in  males  than  in  females 
be  affected. 


Fig.  845. — Tuberculous  Kidney.  Speci- 
men IN  THE  Kensington  Hospital, 
Philadelphia. 


Either  kidney  may 


'Walker,  George:  "Renal  Tuberculosis,"  Johns  Hopkins  Hosp.  Rep.,  1904,  xii,  455. 

"  Stewart,  D.  D.,  and  Kelly,  A.  O.  J.:  "On  the  Occurrence  of  Primary  Tuberculosis  of  the 
Kidney,  with  Special  Reference  to  a  Primary  Miliary  Form,"  Med.  News,  Aug.  14-21,  1897,  p. 
193. 

^Hunner,  G.  L.:  "Tuberculosis  of  the  Urinary  System  in  Women;  Report  of  Thirty-five 
Cases,"  Johns  Hopkins  Hosp.  Bull.,  1904,  xv,  No.  154,  p.  8. 


784  SURGERY  OF  THE  KIDNEY. 

Pathology. — A  tuberculous  infection  may  reach  the  kidney  through  the  blood 
(the  usual  route),  by  extension  from  surrounding  organs,  as  tuberculous  disease  of 
the  vertebra,  and,  it  has  been  stated  in  the  past,  by  an  extension  upward  from  the 
bladder.  This  form,  or  ascending  infection  from  the  bladder,  is  very  rare,  if  it 
occurs  at  all.  No  such  case  has  been  observed  by  either  of  the  authors.  The 
conditions  for  its  occurrence  are  more  favorable  in  the  male  than  in  the  female. 

Predisposing  causes  are  trauma  of  the  kidney  or  diseases  which  lower  its  resist- 
ance. Among  the  latter  may  be  mentioned  kidney  stone,  acute  nephritis,  and 
any  disease  of  the  lower  urinary  tract  which  leads  to  a  stasis  or  obstruction  of  the 
flow  of  urine. 

When  infection  occurs  by  way  of  the  blood,  renal  tuberculosis  may  appear  in  a 
miliary  or  in  a  caseous  form.  Miliary  tuberculosis  of  the  kidney  as  a  part  of  a 
general  miliary  tuberculosis  has  no  surgical  interest.  The  caseous  variety  differs 
in  its  gross  appearance  as  to  whether  the  ureter  is  obstructed  or  not.  According 
to  Walker,  when  the  ureter  is  patent,  the  kidney  may  not  be  enlarged.  It  is  usually 
irregularly  lobulated,  some  of  the  lobules  being  hard,  others  soft  and  fluctuating. 
Scattered  throughout  the  cortex  and  medufla  there  are  "nodular  areas  composed 
of  grayish-white  and  yellowish-gray  masses."  These  are  prone  to  be  collected 
at  the  poles.  Later  they  coalesce  and  liquefy,  forming  cavities  with  irregular, 
ragged,  grayish-red  walls  and  grumous  contents.  Larger  cavities  are  formed  by 
the  destruction  of  the  intervening  kidney  tissue  and  the  coalescence  of  smaller 
ones.  The  entire  kidney  may  be  converted  into  an  abscess  sac.  Cysts  the  size 
of  a  fllbert  are  sometimes  observed  in  the  renal  substance.  They  are  produced 
by  the  obstruction  of  an  excretory  tubule  coming  from  a  healthy  part  of  the  kidney 
parenchyma. 

When  the  ureter  is  blocked  (tuberculous  disease  of  the  ureter  or  tuberculous 
debris  or  blood-clot  in  the  ureter),  there  may  be  a  rapid  destruction  of  the  entire 
kidney  by  caseous  degeneration  without  much  enlargement,  or  there  may  be  at 
first  a  moderate  degree  of  hydronephrosis  followed  by  liquefaction  of  the  caseous 
material  and  the  conversion  of  the  kidney  into  a  large  abscess,  occasionally  three 
or  four  times  the  size  of  the  normal  organ.  In  the  typical  hydronephrotic  form 
there  is  less  invasion  of  the  kidney  substance,  although  it  finally  atrophies  from 
pressure.  A  large  fluctuating  tumor  is  formed,  containing  turbid  fluid,  in  which 
the  tubercle  bacillus  may  be  demonstrated  by  injecting  a  guinea-pig.  Tuberculous 
lesions  in  the  pelvis  and  calyces  are  usually  present. 

The  ascending  form  of  renal  tuberculosis  is  very  rare  in  women.  Vesical 
tuberculosis  in  the  female  sex  is  almost  invariably  secondary  to  renal  tuberculosis. 
In  men  tuberculosis  of  the  bladder  may  be  secondary  to  tuberculous  orchitis, 
epididymitis,  and  seminal  vesiculitis.  Tuberculous  cystitis  in  men  is  usually 
secondary  to  a  kidney  lesion. 

In  the  ascending  form  of  renal  tuberculosis,  it  is  said,  there  is  some  obstructive 
lesion  of  the  lower  urinary  organ  leading  to  a  stasis  of  urine.  The  lesions  first 
become  apparent  in  the  pelvis  and  calyces.     The  disease  extends  finally  to  the  kid- 


TUBERCULOSIS    OF   THE    KIDNEY.  785 

ney  substance,  and  the  entire  organ  may  be  converted  into  an  abscess  or  a  cheesy 
mass. 

"When  the  kidney  becomes  tuberculous  from  the  extension  of  a  neighboring 
lesion,  the  organ,  as  a  rule,  is  directly  invaded  by  an  erosion  of  its  capsule.  The 
organ  may  possibly  be  infected  through  the  lymphatics  and  the  capsule  remain 
intact.  ^Mien  the  capsule  is  eroded,  there  is  usually  no  change  in  the  size  of  the 
organ  until  the  process  is  well  advanced. 

A  tuberculous  process  in  the  kidney  may  be  complicated  by  a  mixed  infection. 
In  such  event  the  destructive  process  is  intensified  and  suppuration  occurs. 

Tuberculosis  may  be  associated  with  kidney  calculus.  Each  may  intensify 
the  other.  Calculus  has  often  appeared  to  be  a  predisposing  cause  of  tuberculosis, 
and  tuberculous  lesions  undoubtedly  may  become  calcified  and  lead  to  the  forma- 
tion of  stone. 

A  tuberculous  process  may  exist  in  one  kidney  for  a  long  time  without  any  in- 
volvement of  the  opposite  organ;  Walker  believes  that  in  the  majority  of  cases 
two  years  may  elapse.  The  opposite  kidney  has  been  found  tuberculous  in  9  per 
cent,  and  the  seat  of  nephritis  in  8  per  cent,  of  cases  at  the  time  of  operation. 

Reports  of  renal  tuberculosis  found  at  autopsy  indicate  a  much  larger  ratio  of 
involvement  of  the  second  kidney.  Both  organs  were  involved  in  all  but  three 
of  sixty-one  cases  collected  by  Walker.  Some  form  of  nephritis  of  the  second 
kidney  exists  in  78  per  cent,  of  the  cases  examined  post-mortem,  and  is  apparently 
due  to  the  excretion  of  tuberculous  toxins. 

According  to  Gaultier  (quoted  by  Walker),  the  ureter  is  involved  in  from  10 
to  12  per  cent,  of  cases  of  renal  tuberculosis.  Although  bladder  s}Tnptoms  are 
customary,  actual  tuberculous  involvement  is  not  so  frequent.  A  marked  cystitis 
is  quite  common.  The  latter  is  caused  by  the  irritation  of  the  tuberculous  products 
coming  from  the  kidney.  The  mucosa  surrounding  the  mouth  of  the  ureter  is 
especially  involved  on  the  affected  side.  According  to  Walker,  "the  bladder  is 
implicated  fairly  early,  and  very  few  cases  show  a  duration  of  more  than  eight 
months  without  tuberculous  invasion  of  this  viscus." 

Symptoms. — Tuberculosis  of  the  kidney  may  begin  insidiously  and  give  rise 
to  few  or  no  symptoms  until  the  process  is  considerably  advanced.  Cases  have  been 
found  at  autopsy  in  which  there  had  been  no  symptoms.  The  manifestations  of 
the  disease  and  the  time  of  their  first  appearance  depend  upon  the  location  of 
the  process  and  the  accidents  to  which  it  may  be  subjected.  Thus,  a  tuberculous 
lesion  near  the  renal  calyces  or  pelvis  would  usually  produce  symptoms  sooner 
than  foci  in  the  cortex,  and  a  lesion  early  infected  by  pyogenic  organisms  would  show 
itself  much  quicker  than  an  uncomplicated  one.  There  may  be  no  symptoms 
until  the  disease  has  reached  the  calyces  or  pelvis. 

The  first  symptom  usually  is  an  irritability  of  the  bladder  associated  with 

pohiiria.     The  patient  complains  of  a  frequent  and  intense  desire  to  urinate  and 

has  pain  after  completing  the  act.     Renal  colic  may  be  the  first  manifestation  of 

tuberculosis,  if  a  previously  quiescent  focus  bursts  into  the  kidney  pelvis.     If  the 
VOL.  II — 50 


786  SUKGERY  OF  THE  KIDNEY. 

tuberculous  process  is  so  situated  that  it  soon  causes  the  erosion  of  a  papillary  blood- 
vessel, hemorrhage  may  be  an  early  and  a  very  alarming  symptom. 

Shortly  after  the  onset  of  symptoms  pyuria  and  hematuria  appear.  Neither 
may  be  more  than  microscopic,  or  the  urine  may  be  putrid  with  pus  or  scarlet 
with  blood.  Sometimes  there  may  be  granular  and  hyaline  casts.  Albumin  at 
first  is  in  direct  proportion  to  the  pus  and  blood ;  later  there  is  an  essential  albumi- 
nuria, from  either  the  affected  kidney  or  its  fellow.  The  urine  in  advanced  cases 
contains  kidney  and  pelvic  epithelium.  Occasionally  there  is  renal  tissue  or  con- 
nective tissue  and  elastic  fibers  and  little  clumps  of  meal-like  detritus  (White  and 
Martin).  Tubercle  bacilli  may  antedate  pyuria.  The  urine  does  not  become 
alkaline  unless  mixed  infection  occurs.  Then  there  may  be  considerable  mucous 
sediment  and  the  urine  may  be  foul-smelling.  Clear  urine  may  alternate  with 
pyuria  if  the  bladder  is  clean,  the  affected  side  is  obstructed,  and  the  opposite 
kidney  is  healthy.  If  pus  occurs  in  great  quantities,  there  is  probably  a  mixed 
infection,  and  staphylococci,  colon  bacilli,  or  streptococci  will  be  found  in  the 
urine. 

There  may  be  a  constant  feeling  of  discomfort  or  uneasiness  in  the  renal  region, 
with  tenderness  on  deep  pressure;  or  there  may  occur  from  time  to  time  attacks  of 
renal  colic.  These  attacks  are  produced  by  blockage  of  the  ureter  with  masses  of 
tuberculous  detritus  or  blood-clot,  or  they  may  occur  from  inflammatory  conges- 
tion. 

At  first  there  is  no  change  in  the  abdominal  wall.  Later,  particularly  if  the 
paranephritic  tissues  are  involved,  there  may  be  rigidity.  The  kidney  tumor 
varies  from  a  slight  enlargement  to  a  tumor  filling  half  the  abdomen,  the  average 
size  being  one  and  a  half  times  that  of  the  normal  kidney.  At  first  the  tumor  is 
firm,  but  later  it  shows  fluctuating  areas,  and  finally  becomes  a  soft  fluctuating 
mass.  When  the  left  kidney  is  affected,  the  spleen  is  pushed  forward  and  the  renal 
enlargement  is  obscured.  When  the  perirenal  tissues  are  involved,  the  mass  is 
much  greater  and  more  superficial. 

There  is  usually  a  slight  evening  rise  of  temperature  as  the  disease  advances. 
Later  it  is  more  marked  and  varies  in  twenty-four  hours  from  4°  to  5°  F.  If  there 
is  a  secondary  infection,  it  may  rise  to  105°  F.  Fever  may  occur  only  when  the 
urine  is  clear,  the  rise  of  temperature  being  due  to  retention  of  pus  within  the  kid- 
ney. Exhausting  sweats,  emaciation,  and  anemia  fill  out  the  clinical  picture  in 
advanced  cases. 

Diagnosis. — Tuberculosis  of  the  kidney  may  be  mistaken  for  renal  calculus, 
pyelonephritis,  tumors,  and  functional  hematuria. 

Significant  symptoms  of  tuberculosis  are  persistent  dysuria  with  an  increased 
excretion  of  acid  urine  in  the  absence  of  a  bladder  or  ureteral  lesion.  Continued 
pyuria,  or  occasional  hematuria  with  acid  urine,  and  irritability  of  the  bladder, 
are  highly  suggestive.     Kelly^  reports  Caspar  as  insisting  that  when  there  is  con- 

1  Kelly,  H.  A.:  "Some  Surgical  Notes  on  Tuberculosis  of  the  Kidney,"  Brit.  Med.  Jour., 
June  17,  1905,  p.  1319. 


TUBERCULOSIS    OF   THE   KIDNEY.  787 

tinuous  acid  pyuria  and  the  urine  obtained  by  catheterization  does  not  yield  a  growth 
of  organisms  on  the  ordinary  culture-media,  the  case  should  be  suspected  as  one  of 
tuberculosis. 

Pain  at  the  end  of  urination  with  a  frequent  intense  desire  to  void  urine  may 
exist  before  there  are  any  visible  alterations  in  the  bladder.  Later  there  may  be 
marked  cystitis  or  an  actual  tuberculous  disease  of  the  bladder.  The  ureteral 
orifice  of  the  affected  side  is  edematous,  congested,  or  positively  inflamed,  and  the 
region  of  the  ureter  is  the  site  of  either  inflammation  or  ulceration.  Between  the 
ureter  and  the  trigone  there  are  a  number  of  clearly  defined  inflamed  areas  of 
mucous  membrane  with  unchanged  mucosa  between  them,  which  Meyer^  com- 
pares to  "footprints  in  freshly  fallen  snow."  According  to  Schede,  actual  disease 
begins  at  the  mouth  of  the  ureter  as  grayish  kernels  visible  in  the  mucosa;  they 
grow  larger,  coalesce,  and  break  down  into  an  ulcer  with  a  grayish  base  and  ragged 
edges.  The  bladder  is  in  a  state  of  almost  constant  contraction,  and  its  capacity 
may  be  diminished  to  30  to  50  c.c.  In  advanced  cases  the  bladder  feels  enlarged 
and  thickened. 

In  renal  calculus,  dysuria  is  not  so  marked,  the  hemorrhage  is  more  profuse 
upon  exertion,  and  there  is  less  failure  in  the  general  health.  In  all  cases  of  sus- 
pected tuberculosis  an  x-ray  picture  should  be  made  to  exclude  the  possibility  of 
stone. 

Infection  of  the  kidney  (pyelonephritis)  is  more  violent  in  its  course;  local 
kidney  symptoms  develop  quickly  and  are  pronounced,  and  there  is  less  apt  to  be 
induration  and  thickening  of  the  lower  part  of  the  ureter. 

Tumors  show  less  or  no  fever,  no  local  inflammatory  symptoms,  no  pyuria, 
more  hematuria;   the  kidney  enlarges  rapidly  and  cachexia  supervenes. 

For  a  discussion  of  essential  renal  hemorrhage,  which  may  suggest  tuberculosis 
of  the  kidney,  see  page  815. 

In  renal  tuberculosis  there  may  be  evidence  of  tuberculosis  elsewhere  in  the 
body,  either  past  or  present.  The  indication  of  previous  disease  may  exist  in 
swellings  or  scars  in  the  region  of  the  submaxillary,  cervical,  axillary,  and  .ingui- 
nal glands,  or  there  may  be  lesions  in  the  lungs,  bladder,  seminal  vesicles,  prostate 
gland,  and  epididymis. 

The  sediment  of  a  considerable  quantity  of  urine  obtained  from  the  bladder 
if  it  is  healthy,  or  from  the  ureter  of  the  diseased  side  if  the  bladder  is  involved, 
should  be  secured  in  an  aseptic  manner  and  injected  into  the  peritoneal  cavity  of  a 
guinea-pig.  If  the  urine  comes  from  a  tuberculous  kidney,  the  animal  usually 
dies  in  from  three  to  five  weeks;  if  death  does  not  occur,  the  animal  should  be  killed 
at  the  end  of  six  weeks  and  examined. 

In  the  meantime  a  couple  of  smears  from  the  urinary  sediment  should  be  stained 
each  day  and  examined  for  tubercle  bacilli.  Walker  allows  the  urine  to  settle 
in  a  conical  glass  for  twelve  hours.     The  slides  are  boiled  for  thirty  minutes  in  caus- 

^  Meyer,  Willy:  "Early  Diagnosis  and  Early  Nephrectomy  for  Tuberculosis  of  the  Kidney," 
Med.  News,  May  1,  1897. 


788  SURGERY  OF  THE  KIDNEY. 

tic  soda  and  then  washed  for  half  an  hour  in  order  to  render  them  absolutely  free 
from  fat,  wiped  dry,  and  two  drops  of  the  sediment  are  placed  on  each  slide.  The 
slides  are  placed  ten  inches  above  a  Bunsen  burner  and  dried.  They  are  fixed 
in  the  flame  and  then  placed  in  a  5  per  cent,  solution  of  hydrochloric  acid  in  alcohol 
for  five  minutes  to  dissolve  the  urinary  salts.  After  washing  carefully  in  running 
water  they  are  stained  for  ten  minutes  with  carbol-fuchsin  and  decolorized  with 
Gabbett's  blue.  If  pus  is  present  in  small  amounts  only,  the  urine  is  centrifugal- 
ized  in  order  to  obtain  the  sediment.  Care  must  be  observed  even  in  catheterized 
specimens  lest  the  smegma  bacillus  be  mistaken  for  the  tubercle  bacillus.  In 
order  to  exclude  the  smegma  bacillus,  stain  in  the  usual  way  with  carbol-fuchsin, 
decolorize  with  25  per  cent,  nitric  acid,  wash  the  slide  for  two  minutes  with  95 
per  cent,  alcohol,  and  counter-stain  with  methylene-blue.  In  some  cases  it  will  be 
necessary  to  inoculate  a  guinea-pig  in  order  to  exclude  the  smegma  bacillus. 
No  method  of  staining  is  absolutely  reliable.  The  guinea-pig  test  is  the  best  means 
of  making  a  positive  diagnosis,  especially  in  early  cases. 

In  general  it  may  be  said  that  the  tuberculin  test  as  a  means  of  diagnosis  is  not 
very  reliable  and  it  may  even  be  harmful.  Guiteras^  believes  that  a  positive  reac- 
tion after  an  injection  of  tuberculin  is  a  very  strong  evidence  of  an  active  tubercu- 
lous lesion.  A  negative  result  is  not  so  valuable,  for  in  a  certain  number  of  old 
encapsulated  tubercles  a  positive  reaction  does  not  occur  even  though  a  considerable 
dose  has  been  given.  In  using  the  tuberculin  test  the  temperature  should  be  taken 
every  two  hours  for  three  days  preceding  the  injection.  The  tuberculin  must  be 
carefully  prepared  and  tuberculous  foci  elsewhere  in  the  body  must  be  excluded  in 
drawing  conclusions.  This  source  of  error  cannot  be  eliminated  in  many  cases. 
The  ophthalmo-tuberculin  test,  Calmette's  reaction,  may  be  useful. 

It  is  advisable  in  all  cases  to  determine  the  exact  conditions  of  the  second  kidney. 
If  there  is  no  vesical  disease,  both  ureters  may  be  catheterized.  If  the  bladder  is 
the  seat  of  infection,  catheterization  of  the  presumably  sound  ureter  should  be 
avoided  if  possible.  That  there  is  danger  from  catheterization  of  the  sound  side 
is  shown  by  Hunner,"  who  reports  a  case  which  resulted  in  the  ultimate  disease  of 
the  healthy  kidney.  He  believes  the  practice  unnecessary,  and  recommends  either 
gathering  the  urine  from  the  healthy  ureter  by  simply  holding  the  speculum  under 
the  ureteral  orifice,  or  catheterizing  the  diseased  side,  washing  out  the  bladder 
thoroughly,  and  then  taking  the  urine  which  collects  there  in  the  next  few  minutes 
as  representing  the  opposite  side.  Allowance  is  made  for  a  few  pus  and  epithelial 
cells  from  the  bladder.  If  it  becomes  necessary  to  catheterize  the  sound  size,  it  will 
be  wise  to  follow  the  plan  of  Noble,^  who  irrigates  the  bladder  immediately  preced- 

^Guiteras,  Ramon:  "  Diagnosis  and  Surgical  Treatment  of  Tuberculosis  of  the  Kidney," 
Detroit  Med.  Jour.,  1903,  iii,  1. 

2  Hunner,  Guy  L.:  "Tuberculosis  of  the  Urinary  System  in  Women,"  Johns  Hopkins  Hosp. 
Bull.,  1904,  vol.  XV,  No.  154,  p.  8. 

^  Noble,  Charles  P.:  "Tuberculosis  of  the  Kidney,"  Surg.,  Gynec.  and  Obstet.,  1907,  iv, 
March,  p.  264. 


KIDNEY    stone;    RENAL   CALCULUS;    NEPHROLITHIASIS.  789 

ing  cystoscopic  examination,  and  before  inserting  the  ureteral  catheter  wipes  the  ori- 
fice of  the  ureter  with  a  pledget  of  cotton  and  bichlorid  solution  1  :  10,000.  Or  the 
ureters  may  be  catheterized  after  distention  of  the  bladder  with  boric  acid  solution 
through  a  catheterizing  cystoscope. 

Kelly  warns  that  the  opposite  healthy  kidney  may  be  enlarged  and  com- 
pensating and  must  not  be  mistaken  for  the  diseased  organ.  Such  an  error  has 
been  made,  the  healthy  organ  being  extirpated  instead  of  the  diseased  one. 

Prognosis. — Renal  tuberculosis  may  cause  death  within  several  months  or 
life  may  be  prolonged  for  a  number  of  years.  It  shows  no  tendency  to  undergo 
spontaneous  cure,  and  a  subsidence  of  the  disease  is  only  secured  in  a  few  cases, 
after  the  kidney  parenchyma  has  been  entirely  destroyed  and  the  organ  converted 
into  a  fibrous  mass. 

Treatment. — The  only  hope  of  a  cure  lies  in  an  early  nephrectomy.  Time  spent 
in  climatic  and  other  treatment  is  lost.  Unless  contraindicated  by  the  general 
condition  of  the  patient  or  by  involvement  of  the  second  kidney,  nephrectomy 
should  be  performed  as  soon  as  a  diagnosis  is  made.  If  the  second  kidney  is  also 
tuberculous,  nephrectomy  would  be  ill  advised.  Under  such  circumstances, 
primary  nephrotomy  of  the  most  diseased  organ  is  best,  followed  by  nephrectomy 
later  if  the  organ  is  functionally  useless  or  nearly  so.  In  the  case  of  an  advanced 
or  active  tuberculous  lesion  of  the  lung  nephrectomy  cannot  be  performed  with 
safety;  nephrotomy  and  drainage  may  be  substituted.  Nephrotomy  in  a  tubercu- 
lous kidney  usually  gives  very  unsatisfactory  results  and  should  rarely  be  employed; 
and  then  only  to  stop  septic  absorption  or  to  permit  a  final  determination  of  the 
functional  capacity  of  the  opposite  kidney. 


KIDNEY  STONE?     RENAL  CALCULUS;    NEPHROLITHIASIS. 

Etiology. — Kidney  stone  as  met  with  in  surgical  practice  occurs  most  fre- 
quently in  patients  between  the  ages  of  thirty  and  fifty.  Precipitates  of  uric  acid 
and  small  calculi  are  rather  frequently  found  in  the  kidney  pelvis  of  infants  and 
young  children.  Most  of  them  are  so  small  that  they  are  washed  out  by  the  urine, 
but  occasionally  they  give  rise  to  symptoms  and  require  treatment,  and  many  cases 
of  calculus  coming  to  operation  later  in  life  are  undoubtedly  due  to  deposits  begin- 
ning in  childhood.  Nephrolithiasis  is  more  common  in  the  male  than  in  the  female. 
The  disease  is  more  frequent  in  tropical  countries,  although  its  distribution  varies 
widely  in  different  parts  of  the  globe. 

There  is  probably  no  more  hereditary  predisposition  to  calculus  than  that 
which  pertains  to  the  uric  acid  diathesis.  Cases  have  been  reported,  however, 
of  kidney  stone  in  several  members  of  the  same  family,  even  though  they  lived 
widely  apart  and  under  different  conditions  of  life. 

There  is  no  constant  relation  between  the  chemical  composition  of  the  drink- 
ing-water and  the  frequency  of  nephrolithiasis.  The  amount  of  water  consumed 
by  the  individual  is  probably  of  more  importance  in  this  connection,  an  abim- 


790 


SURGERY   OF   THE   KIDNEY. 


dance  acting  as  a  prophylactic  measure  by  diluting  the  urine  and  rendering  pre- 
cipitation of  its  salts  less  likely. 

A  very  rich  diet,  composed  largely  of  nitrogenous  food,  is  conducive  to  kidney 
stone;  and  the  same  may  be  said  of  an  insufficient  diet,  especially  in  the  children  of 
the  poorer  classes  who  are  fed  on  substitutes  for  fresh  milk. 

Certain  lesions  associated  with  a  rapid  destruction  of  bone,  as  osteomalacia  or 
multiple  bone  tumors,  result  in  an  excess  of  lime  salts  in  the  blood  and  the  formation 
of  calculi. 

The  uric  acid  diathesis  favors  the  concretion  of  calculi  by  raising  the  amount 

of  uric  acid  in  the  urine, 
thus  increasing  the  degree 
of  its  precipitation. 

People  of  sedentary 
habits  are  especially  predis- 
posed to  kidney  calculus. 

Pathology. — K  i  d  n  e  y 
calculi  usually  originate 
from  a  deposit  of  urinary 
salts  upon  an  organic  basis. 
This  organic  matter  may 
be  a  ball  of  mucus,  or  a 
clump  of  necrotic  and  des- 
quamated epithelium,  or  a 
blood-clot,  or  the  eggs  or 
^^  the  body  parts  of 
certain  parasites,  as 
the  distoma  hema- 
tobium  or  the  filaria  san- 
guinis hominis.  Foreign 
bodies  and  agglutinations 
of  bacteria  appear  to  have 
formed  the  nucleus  in  some 
cases.  Detached  particles 
of  a  new-growth  or  of  a 
tuberculous  focus  may  act 
in  the  same  way.  In  the 
great  majority  of  cases,  at  the  time  the  stone  is  removed  no  nucleus  can  be  demon- 
strated. 

After  the  nucleus  has  been  formed,  the  stone  increases  in  size  by  successive 
deposits  and  incrustations  of  urinary  salts  upon  its  surface.  Changes  in  the  com- 
position of  the  urine  during  the  life  of  a  stone  often  result  in  the  precipitation  of  a 
different  salt  than  the  one  originally  thrown  down. 

Kidney  calculi  may  be  composed  of  uric  acid  or  urates,  calcium  oxalate  or  triple 


Fig.  846. — Calculous  Pyonephrosis. 
Kidney  destroyed;   stone  blocking  the  ureter. 


KIDNEY   stone;    RENAL   CALCULUS;   NEPHROLITHIASIS,  791 

phosphates,  named  in  the  order  of  frequency.  The  first  two  are  usually  deposited 
from  acid  urine  and  the  last  from  alkaline  urine.  Phosphatic  stones  are  most 
common  when  nephrolithiasis  follows  infection.  A  stone  may  have  a  nucleus  of 
uric  acid,  a  concentric  ring  of  oxalates  surrounding  this,  and  a  covering  layer  of 
phosphates.     Other  combinations  are  frequent. 

Uric  acid  stones  are  yellow,  yellowish-brown,  or  reddish-brown.  Oxalate 
stones  are  usually  rough  externally,  and  have  been  called  mulberry  calculi,  and  are 
the  hardest  variety  of  stone.  Phosphatic  calculi  are  of  a  white  or  dark  gray  color 
and  are  usually  softer  than  the  others.  Calculi  may  be  formed  also  of  cystin, 
xanthin,  carbonates,  etc.  Kidney  stones  vary  in  weight  from  3  to  300  gm.  and  in 
number  from  one  to  one  hundred  or  even  one  thousand.  In  seven  hundred  and 
nine  surgical  cases  collected  bv  Kiister  there  was  one  stone  in  four  hundred  and 
twenty-one  instances,  two  stones  in  forty-seven,  and  more  than  two  in  two  hundred 
and  forty-one. 

The  configuration  of  kidney  calculi  depends  upon  their  position  and  number. 
Single  stones  in  the  pelvis  or  in  the  kidney  substance  are  more  or  less  rounded ;  they 
may  be  oval  or  flattened  and  bean-like.  Their  surface  is  usually  covered  with  fine 
sand,  or  there  may  be  flat  elevations  or  sharp  points. 

Stones  overlying  the  ureteral  orifice  may  be  tunneled  or  there  may  be  a  groove 
on  one  side  through  which  the  urine  finds  entrance  to  the  ureter.  At  other  times 
stones  in  this  position  project  into  the  ureter  like  a  nail  with  its  head  lying  in  the 
pelvis. 

A  single  kidney  calculus  often  fills  the  entire  pelvis  of  the  kidney,  being  molded 
into  its  shape  and  being  branched  like  a  piece  of  coral  and  fitting  closely  into  the 
calyces  (Fig.  847) ;  or  the  stone  formation  filling  the  pelvis  and  calyces  may  consist 
of  several  calculi,  fitted  together  and  faceted  at  their  points  of  contact.  Incrusta- 
tion of  the  wall  of  the  kidney  pelvis  with  phosphates  may  occur  in  the  presence 
of  infection  when  the  urine  is  alkaline.  The  salts  are  deposited  usually  in  necrotic 
or  ulcerating  parts  and  the  pelvis  is  converted  into  a  resistant  hard  shell. 

A  renal  stone  lying  in  the  kidney  substance  is  surrounded  by  a  smooth-walled 
sac  made  up  of  the  dilated  kidney  tubule  in  which  the  stone  originally  began,  and 
in  the  absence  of  infection  may  give  very  little  trouble.  Usually  it  causes  some 
mild  nephritis  in  its  neighborhood  and  modifies  the  secretory  and  the  excretory 
functions  of  the  surrounding  tubules. 

A  stone  lying  in  a  calyx  may  completely  abrogate  the  function  of  the  correspond- 
ing part  of  the  kidney.  The  orifice  of  the  calyx  usually  contracts,  leaving  a  very 
narrow  communication  with  the  kidney  pelvis;  or  the  calyx  may  be  closed  off 
entirely,  so  that  at  first  sight  the  stone  appears  to  be  lying  in  the  kidney  substance. 

A  stone  in  the  kidney  pelvis  is  apt  to  produce  excoriations  of  the  mucosa  and 
hemorrhage. 

If  the  stone  is  not  fixed,  it  may  cause  an  intermittent  obstruction  of  the  ureteral 
orifice ;  when  impacted  in  the  ureteral  orifice,  obstruction  will  be  complete.  When 
the  obstruction  is  frequently  repeated  or  permanent  and  there  is  no  infection,  a 


792 


SURGERY    OF   THE   KIDNEY. 


dilatation  of  the  kidney  pelvis  and  the  calyces  and  an  atrophy  of  the  parenchyma 
usually  occur,  the  process  closely  resembling  that  described  in  hydronephrosis. 
There  may  be  little  dilatation,  but  a  rapid  atrophy  and  a  shrinkage  of  the  organ 
until  it  is  represented  finally  by  little  more  than  a  fibrous  capsule  inclosing  the  stone. 
There  is  a  great  tendency  for  the  kidney  to  become  infected  in  nephrolithiasis. 
The  bacteria  may  come  from  the  blood  exuding  from  an  excoriation  of  the  mucous 
membrane,  or  there  may  be  an  ascending  infection  from  the  bladder.  After  infec- 
tion occurs,  the  urine  becomes  alkaline  and  the  stones  are  coated  with  a  deposit 
of  phosphates  and  increase  in  size  with  greater  rapidity  than  before.  Pyeloneph- 
ritis associated  with  calculus  has  a  course  very  like  that  described  for  non-calculus 

pyelonephritis  (p.  778).  It  differs  from  the 
latter,  however,  in  its  greater  intensity  and 
by  the  occurrence  of  free  hemorrhage  within 
the  kidney  pelvis.  Blood-clots  in  the  pelvis 
are  converted  into  grayish  or  grayish-green 
masses  interpenetrated  with  urinary  salts. 
The  kidney  may  be  converted  into  a  bag  of 
pus,  made  up  of  numerous  loculi  (Fig.  846), 
either  isolated  or  communicating  with  one 
another.  A  single  stone  may  send  branches 
into  each  of  these  loculi,  or  they  may  be  oc- 
cupied by  separate  stones,  or  single  stones 
may  lie  in  separate  abscess  cavities  within 
the  kidney  parenchyma. 

Calculous  pyelonephritis  frequently  ex- 
tends to  the  paranephritic  tissue,  either  by 
direct  erosion  of  the  kidney  cortex  or  by 
lymphatic  extension  from  the  pelvis  without 
participation  of  the  kidney  substance.  In 
case  of  a  direct  extension  the  stone  may  pass 
into  the  paranephritic  tissue  or  remain  in  the 
kidney.  From  a  paranephritic  abscess  a 
stone  may  participate  in  any  of  those  exten- 
sions into  neighboring  organs  and  tissues, 
which  are  more  or  less  common  to  this  disease.  In  such  a  way  stones  have  reached 
the  intestines,  the  lungs,  the  axilla,  and  the  thigh.  Or  the  stone  may  remain 
stationary  and  the  abscess  burrow.  Deep  fistula  in  the  lumbar  region,  in  the  ab- 
sence of  tuberculosis  or  caries  of  the  spine  or  ribs,  almost  always  indicates  stone  m 
the  paranephritic  tissues. 

An  increase  in  the  size  of  the  fatty  capsule  simulating  a  tumor  formation  some- 
times occurs  in  calculous  pyelonephritis  and  is  usually  associated  with  an  atrophy 
of  the  kidney;  or  the  fatty  capsule  may  form  a  shell  of  a  bony  hardness  around  the 
kidney 


Fig.  847.  —  Stones  Removed  from  Right 
Kidney. 
Note  the  cup-like  base  of  a  broken  fragment 
on  the  posterior  face  near  the  center  of  the  large 
stone.  The  calyx  portion  was  probably  left,  and 
may  have  given  rise  to  the  abscess  found  at  the 
second  operation. 


KIDNEY   stone;    RENAL    CALCULUS;    NEPHROLITHIASIS.  793 

Condition  of  the  Opposite  Kidney. — Inasmuch  as  kidney  stone  is  largely 
due  to  constitutional  causes,  it  is  not  surprising  to  find  that  the  disease  is  often 
bilateral.  Even  if  there  is  no  stone  in  the  second  kidney,  it  may  be  the  seat  of  other 
morbid  changes.  To  have  a  calculus  in  one  kidney  and  a  perfectly  healthy  op- 
posite organ  is  by  no  means  invariable.  The  diathetic  condition  responsible  for  a 
unilateral  nephrolithiasis  frequently  generates  some  form  of  nephritis  in  the  op- 
posite kidney.  Some  authors  state  that  in  nearly  50  per  cent,  of  the  cases,  nephro- 
lithiasis is  bilateral,  but  Morris  regards  this  as  an  exaggeration.  He  found  the 
second  kidney  affected  by  calculus  in  not  more  than  10  per  cent,  of  the  cases.  In- 
fection of  the  calculous  kidney  usually  produces  alkalinity  of  the  urine  and  this 
favors  the  formation  of  calculi  in  the  opposite  kidney. 

Symptoms. — There  are  no  pathognomonic  symptoms  of  kidney  calculus, 
positive  diagnoses  being  made  only  by  direct  bimanual  palpation  of  the  stone 
through  the  abdominal  wall,  the  passage  of  a  wax-tipped  ureteral  bougie  into  the 
kidney  pelvis,  an  a;-ray  picture,  or  an  exploratory  operation. 

Aseptic  Cases. — According  to  Musser,^  the  most  constant  symptom  is  pain  in 
the  affected  organ.  The  pain  is  increased  by  movement,  by  jolting,  and  by  pres- 
sure. It  comes  and  goes,  and  is  more  commonly  intermittent  and  paroxysmal. 
It  is  frequently  constant  and  is  localized  over  the  kidney  and  posteriorly  along  the 
margin  of  the  last  rib  of  the  affected  side.  That  it  may  occur  spontaneously  is 
not  so  much  significant  of  renal  calculus  as  that  it  can  be  excited  by  pressure  and 
movement.  In  Musser's  experience  it  comes  on  during  the  day,  especially  the 
latter  part  of  the  day. 

If  the  stone  becomes  displaced  so  that  it  blocks  the  ureter  either  at  its  pelvic 
orifice  or  along  its  course,  renal  colic  occurs.  This  is  a  violent  paroxysmal  pain 
radiating  from  the  lumbar  region  along  the  course  of  the  ureter  to  the  genitalia  and 
the  inner  surface  of  the  thighs.  The  suffering  in  some  cases  is  extreme,  so  that 
the  patient  has  all  the  appearance  of  severe  shock  or  collapse.  Nausea,  retching, 
and  vomiting  are  common.  There  is  marked  vesical  tenesmus,  and  the  patient 
straining  even  after  the  bladder  is  emptied  voids  a  few  drops  of  dark-colored  or 
even  bloody  urine.  The  abdominal  muscles  on  the  affected  side  are  rigid  and 
the  patient  assumes  various  positions  in  an  effort  to  find  one  which  gives  him  ease. 
The  attack  varies  in  duration  from  one  or  two  hours  to  as  many  days.  It  may 
end  as  suddenly  as  it  began.  Relief  is  experienced  as  soon  as  the  obstruction  is 
overcome  by  the  stone  passing  into  the  bladder  or  being  displaced  from  the  mouth 
of  the  ureter  into  some  other  part  of  the  kidney  pelvis,  or  by  the  urine  finding  its 
way  around  the  stone. 

Renal  colic  is  not  characteristic  of  kidney  calculus.  It  is  no  more  than  a  symp- 
tom of  great  tension  within  the  kidney,  and  may  be  occasioned  by  an  acute  inflam- 
mation or  by  a  marked  congestion  of  the  kidney  due  to  a  twisting  of  the  vessels 
at  the  hilus  or  by  an  obstruction  of  the  ureter  from  blood-clots,  inspissated  pus, 
necrotic  tissue,  a  kink,  or  the  action  of  a  valve. 

iMusser,  J.  H.:     "Renal  Calculus,"  Phila.  Med.  Jour.,  April  16,  1898,  p.  681. 


794  SURGERY   OF   THE   KIDNEY. 

The  urine  is  usually  of  a  high  specific  gravity,  containing  albumin  and  a  small 
number  of  long  and  narrow  hyaline  casts.  Hematuria  is  nearly  constant;  the 
amount  of  blood  varies  between  a  quantity  sufficient  to  color  the  urine  bright  red 
(rare)  and  a  few  corpuscles  only  recognized  by  a  microscopic  examination  (common) 
of  the  centrifugated  specimen.  The  urine  may  at  times  be  free  from  blood,  but  the 
daily  study  of  a  specimen  will  invariably  show  a  persisting  hematuria. 

There  may  be  a  burning  or  cutting  pain  on  urination;  the  lips  of  the  ex- 
ternal urinary  meatus  may  be  red  and  swollen  and  show  a  few  crystals  of  urinary 
salts. 

Shortly  or  some  days  after  an  attack  of  renal  colic  a  small  stone  may  be  passed 
or  it  may  be  found  in  the  bladder;  at  other  times  sand  or  gravel  may  be  voided  with 
the  urine.  Pyuria  does  not  occur  unless  the  kidney  or  some  part  of  the  urinary 
tract — the  ureter,  bladder,  prostate,  or  urethra — is  infected. 

Persistent  hematuria,  high  specific  gravity  of  the  urine,  albuminuria,  and  hyaline 
casts  are  prominent  symptoms  of  kidney  calculus. 

If  the  outflow  of  urine  on  the  affected  side  is  blocked  and  the  other  kidney  is 
healthy,  no  abnormal  constituents  may  be  discovered  upon  urinalysis.  In  the 
event  of  an  intermittent  obstruction  the  pathologic  elements  may  only  occasionally 
be  present  in  the  urine.  When  one  ureter  is  blocked  by  a  stone,  there  may  be  a 
failure  of  excretion  from  the  other  kidney,  so  that  the  patient  suffers  from  anuria. 
Sometimes  this  is  nervous  in  origin  and  is  entirely  due  to  an  irritation  arising  in 
the  diseased  kidney  or  ureter;  it  is  then  spoken  of  as  reflex  anuria.  Many  cases 
of  so-called  reflex  anuria  are  really  evidences  of  an  obstruction  of  the  ureter  of  the 
second  kidney  or,  that  there  is  no  second  kidney. 

Septic  Form. — When  pyelonephritis  is  added  to  calculus  of  the  kidney,  fever, 
chills,  sweats,  and  pyuria  make  their  appearance.  The  kidney  enlarges  and 
becomes  acutely  tender.  Uremic  symptoms  appear  after  the  second  kidney  be- 
comes infected. 

Even  a  case  of  infected  calculus  may  have  few  symptoms.  Doran^  reports  a 
case  of  calculous  pyonephrosis  in  which  there  was  no  pain  and  no  fever.  The 
kidney  was  considerably  enlarged  and  cystic  and  contained  pus  and  several  calculi. 
There  was  no  sign  of  inflammation  in  the  tissues  around  the  kidney.  Doran  thought 
that  the  stricture  of  the  ureter  which  was  present  in  the  case  had  been  caused  by  a 
previous  ureteral  calculus,  and  the  subsequent  ulceration  and  contraction  of  the 
ureter  at  the  site  of  the  stone.  The  symptoms  in  this  case  were  mainly  tenderness 
and  nausea  caused  by  the  pressure  of  a  corset,  as  in  a  movable  kidney.  The  patient 
had  noticed  a  swelling  on  the  right  side  for  a  year.  A  corset  made  her  feel  nauseated 
and  the  right  side  ached  a  little.  When  undressed  she  was  always  comfortable. 
After  swallowing  food  there  was  epigastric  pain  and  nausea.  No  hematuria,  no 
renal  colic,  and  no  fever  or  chills  were  ever  observed.  The  abdominal  walls  were 
thin,  the  kidney  was  enlarged  and  could  be  pushed  forward  to  midway  between  the 

^  Doran,  Alban:  "  Painless  Calculous  Pyo-Nephrosiswithout  Fever,  Nephrectomy,  Recovery," 
Brit.  Med.  Jour.,  Mar.  2,  1901,  p.  509. 


KIDNEY   stone;    RENAL    CALCULUS;    NEPHROLITHIASIS.  795 

mammary  and  the  median  lines;  the  surface  was  bilobulated;  fluctuation  was 
obscure  and  there  was  no  tenderness. 

Doran  calls  attention  to  the  experience  of  Bruce  Clark  in  the  post-mortem  room 
at  St.  Bartholemew's  Hospital.  Twenty-four  kidneys  containing  stones  were  dis- 
covered ;  eleven  of  these  had  well-marked  symptoms  during  life,  thirteen  had  not. 

Diagnosis. — Illustrative  of  the  difficulties  experienced  in  the  diagnosis  of  renal 
calculus,  Morris  notes  forty-four  cases  in  which  surgical  operation  was  under- 
taken for  kidney  stone  but  other  conditions  were  found.  Among  these  he  men- 
tions early  tuberculosis,  small  abscess,  suppurating  cyst,  solid  renal  or  perirenal 
tumor  or  cyst,  perinephritis  due  to  sprain  or  trauma,  ureteral  stricture,  ureteral 
valve,  and  displaced  movable  kidney.  Intercostal  neuralgia,  lumbago,  spinal 
caries,  vesical  tumors  and  calculus,  chronic  and  subacute  nephritis,  and  ureteritis 
have  simulated  renal  calculus.  The  only  positive  diagnostic  evidence  of  a  stone 
in  the  kidney  is  furnished  by  palpation,  the  a:-ray,  a  wax-tipped  catheter,  or  an 
exploratory  operation.  A  calculus  in  the  kidney  pelvis  very  rarely  may  be  felt 
when  the  patient  is  thin,  the  stone  is  of  good  size,  and  there  is  no  distention.  If 
there  are  several  stones,  it  is  possible  in  exceptional  cases  to  elicit  crepitus.  A 
stone  may  escape  detection  even  by  direct  palpation  of  the  kidney  delivered  through 
a  lumbar  incision  or  removed  at  autopsy. 

Rontgen  Rays. — According  to  Henry  Pancoast,  "the  radiographic  examination 
is  the  most  uniformly  accurate,  and,  therefore,  the  most  valuable  method  at  our 
command  in  the  diagnosis  of  renal  calculus,  provided  it  is  employed  intelligently. 
The  skiagraphic  findings  cannot  of  themselves,  however,  be  accepted  as  absolute 
in  every  case,  because  of  the  possible  existence  of  certain  sources  of  error,  which, 
though  comparatively  rare,  must  not  be  overlooked.  Therefore  this  method  of 
examination  should  always  be  used  in  conjunction  with  the  other  clinical  methods 
of  diagnosis  and  the  symptoms  which  in  the  first  place  suggest  the  examination. 

"The  degree  of  error  possible  in  any  individual  case  may  be  more  or  less  approxi- 
mately determined  by  consideration  of  the  following  four  definite  factors  concerned 
in  the  accuracy  of  the  results  of  the  radiographic  examination  for  renal  calculus: 
(1)  The  making  of  the  radiograph;  (2)  the  interpretation  of  the  radiograph;  (3) 
anatomic  difficulties;  (4)  other  conditions  or  objects,  normal  or  pathologic,  which 
may  be  capable  of  simulating  the  radiographic  appearance  of  calculus. 

"In  connection  with  the  first  factor  we  may  consider  the  skill  and  experience  of 
the  radiographer,  the  efficiency  of  his  apparatus,  and  the  preliminary  preparation 
of  the  patient.  As  a  rule,  no  radiograph  should  be  accepted  as  of  value  for  the 
diagnosis  of  renal  calculus  unless  the  intestinal  tract  of  the  patient  has  previously 
been  thoroughly  emptied  of  fecal  matter  by  mild  but  efficient  purgation,  aided  when 
possible  by  an  enema.  The  stomach  also  should  be  empty,  especially  when  the 
left  kidney  is  suspected.  The  radiographer  should  be  certain  that  there  is  no 
possibility  of  pills  or  foreign  bodies  of  any  kind  being  present  in  any  part  of  the 
gastro-intestinal  tract. 

"An  accurate  interpretation  of  the  radiograph  requires  equally  as  much  skill 


796  SURGERY  OF  THE  KIDNEY. 

and  experience  as  does  the  examination  itself.  The  x-ray  examination  is  essentially 
a  consultation;  therefore,  the  radiographer  must  possess  a  reasonable  amount  of 
knowledge  of  anatomy  and  surgery;  and,  likewise,  the  surgeon  should  possess  a 
corresponding  degree  of  skill  and  experience  in  interpreting  skiagraphs  of  this  kind. 

"The  anatomic  difficulties  likely  to  influence  the  accuracy  of  renal  skiagraphs 
are  an  excessive  amount  of  fat  in  the  abdominal  walls  or  omentum,  thick  muscular 
walls,  tumors,  and  ascites.  A  reliable  skiagraph  of  the  kidney  area  should  show 
at  least  the  shadows  of  the  psoas  muscles,  and,  to  be  accurate,  the  shadows  of  the 
kidneys  in  addition.  Whether  the  result  of  an  examination  be  positive  or  negative 
as  to  stone,  it  should  be  repeated  before  a  definite  diagnosis  is  made.  Two  negatives 
made  at  the  same  visit  will  not  answer;  the  two  examinations  should  be  made  on 
different  days. 

"A  radiograph  is  a  shadow  picture,  and  unfortunately  there  may  be  present 
somewhere  between  the  x-ray  tube  and  the  plate  other  objects,  usually  abnormal, 
but  which  are  capable  of  making  a  shadow  similar  to  that  of  a  calculus.  This  must 
be  classed  as  an  unavoidable  source  of  error,  though  the  degree  of  error  may  be 
more  or  less  modified  by  the  skill  and  experience  of  the  radiographer.  The  most 
frequent  examples  of  objects  in  the  abdominal  cavity  which  may  produce  misleading 
shadows  are  calcified  lymph-glands,  gas  and  fecal  matter  remaining  in  the  intestinal 
tract  due  to  careless  preparation,  pills  or  tablets  not  broken  up  or  dissolved,  fecal 
concretions,  especially  in  the  appendix,  and  collections  of  pus  in  the  kidneys.  In 
the  pelvis  one  may  be  easily  misled  by  the  frequent  occurrence  of  shadows  due  to 
phleboliths  in  the  pelvic  veins,  intestinal  contents,  calcified  lymph-glands,  and 
sesamoids  in  the  tendons  arising  from  the  spine  of  the  ischium." 

KiimmelP  secured  a  perfect  a--ray  picture  of  a  calculus  in  sixty-five  out  of  eighty- 
four  cases  which  came  to  operation.  There  were  an  equally  large  number  of  other 
kidney  affections  operated  upon  which  simulated  calculus,  but  failed  to  give  a 
positive  a;-ray.  To  secure  good  results  a  carefully  selected  position  of  the  patient, 
a  good  soft  tube,  and  a  well-adapted  diaphragm  are  the  principal  factors.  For 
a  positive  diagnosis  it  will  be  necessary  to  make  several  skiagraphs.  In  each  plate 
the  calculus  must  be  shown  to  be  in  the  same  position.  Kiimmell  regards  this 
constancy  of  position  as  very  important  in  differential  diagnosis,  and  regards  it  as 
a  characteristic  sign  of  stone.  The  position  of  the  stone  on  the  a--ray  plate  is  usually 
several  centimeters  from  the  spinal  column  and  a  little  below  the  twelfth  rib,  cor- 
responding to  the  anatomic  position  of  the  pelvis  of  the  kidney.  This  is  about  the 
point  where  a  horizontal  line  drawn  through  the  body  of  the  second  lumbar  vertebra 
meets  the  twelfth  rib. 

When  renal  calculus  complicates  pyonephrosis,  there  is  a  greater  variation  in  the 
position,  because  such  stones  sink  down  in  the  dilated  and  altered  pelvis  and  grow 
like  coral  rays  into  the  enlarged  calyces.  The  resulting  dentate  mass  is  more  or 
less  characteristic,  and  differentiates  itself  from  intestinal  contents  and  other  acci- 

1  Kummell,  Hermann:  "Modern  Surgery  of  the  Kidney,"  Surg.,  Gynec.  and  Obstet.,  Jan., 
1907,  p.  21. 


KIDNEY   stone;    RENAL    CALCULUS;    NEPHROLITHIASIS.  797 

dental  confusing  elements.  Very  stout  persons  are  unfavorable  subjects  for  the 
diagnosis  of  renal  calculus  by  means  of  the  a;-ray.  The  difficulty  may  be  overcome 
partly  by  compression  of  the  abdominal  wall  at  the  time  the  picture  is  taken.  Pure 
phosphatic  stones,  being  soft,  very  often  give  no  shadow. 

Diagnosis  of  Renal  Stone  by  Means  of  a  Wax-tipped  Bougie. — Kelly ^  uses  a 
renal  bougie,  2  mm.  in  diameter,  with  an  olive  point  3  by  2  mm.  notched  on  two 
sides,  the  notch  running  lengthwise.  The  bougie  is  prepared  by  melting  a  mixture 
of  olive  oil  and  dental  wax,  two  parts  of  wax  to  one  of  oil,  dipping  the  end  of  the 
catheter  in  this,  and  allowing  it  to  harden  in  the  air.  It  then  assumes  a  highly 
polished  surface,  exceedingly  sensitive,  and  abraded  by  the  slightest  contact  with 
any  hard  rough  surface.  In  order  to  locate  the  exact  position  of  the  stone,  whether 
in  the  ureter  or  the  kidney,  it  is  advisable  to  coat  the  entire  length  of  the  bougie. 
A  stone  low  in  the  ureter  produces  a  long  continuous  scratch  extending  along  the 
catheter.  The  chief  source  of  error  in  interpreting  the  marks  on  the  wax  are 
the  scratches  occasioned  by  contact  with  the  cystoscope.  (See  Chapter  XLIII,  p. 
734.) 

Kelly  reports  eighteen  cases  of  kidney  stone  in  which  the  diagnosis  was  positively 
made  by  the  wax-tipped  catheter,  and  in  which  nephrolithotomy  confirmed  the 
diagnosis.  In  two  cases  stones  were  present  and  the  waxed  catheter  failed  to  show 
them.  He  says  the  wax-tipped  catheter  may  fail  to  find  a  renal  calculus  if  the 
pelvis  of  the  kidney  is  much  dilated  and  if  the  stone  is  small,  or  if  the  calculi  are 
lodged  in  cavities  in  the  substance  of  the  kidney,  or  if  a  large  stone  has  fixed  the 
pelvis  of  the  kidney  and  the  catheter  pushes  out  the  upper  end  of  the  ureter  until 
it  forms  a  little  pocket. 

In  doubtful  cases,  when  the  symptoms  are  protracted  or  crippling,  an  explora- 
tory incision  is  justifiable  to  settle  the  diagnosis  of  kidney  calculus. 

Treatment  of  Nephrolithiasis. — Prophylactic. — The  prophylactic  treatment 
of  kidney  stone  consists  in  the  adoption  of  measures  to  dilute  the  urine  and  to  pre- 
vent the  precipitation  of  the  urinary  salts.  The  reader  is  referred  to  standard 
text-books  of  medicine  for  the  hygienic  and  dietetic  treatment  of  the  uric  acid 
diathesis,  oxaluria,  and  phosphaturia. 

In  a  general  way  it  may  be  said  that  an  abundance  of  exercise,  the  avoidance  of 
an  excess  of  nitrogenous  food,  and  the  ingestion  of  large  amounts  of  pure  water  are 
indicated.  When  the  urine  is  very  acid,  the  alkaline  diuretics,  such  as  potassium 
and  lithium  carbonate  (gr.  v  to  xx,  three  to  six  times  daily),  should  be  administered 
in  sufficient  quantity  to  render  the  urine  neutral  or  faintly  acid.  If  the  urine  is 
alkaline,  antiseptics  such  as  urotropin  or  salol  (gr.  x,  t.  i.  d.),  combined  with  benzoic 
acid  (gr.  x,  t.  i.  d.),  are  useful.  Piperazin  (gr.  x  to  xx,  t.  i.  d.)  is  of  special  service  in 
case  the  urine  contains  an  excess  of  uric  acid  or  urates,  as  is  nitrohydrochloric  acid 
(n^  ij  to  V,  t.  i.  d.)  in  the  case  of  oxalates.  All  of  these  drugs  should  be  exhibited 
with  large  drafts  of  water.     The  reaction  of  the  urine  should  be  tested  repeatedly 

'Kelly,  H.  A.:  "My  Experience  with  the  Renal  Catheter  as  a  Means  of  Detecting  Renal 
and  Ureteral  Calculi,"  Amer.  Jour.  Urology,  Oct.,  1904. 


798  SURGERY  OF  THE  KIDNEY. 

and  kept  faintly  acid  by  varying  the  dose  of  the  alkahne  diuretic.  The  dilution  of 
the  urinary  excretion  should  be  determined  by  noting  the  quantity  passed  in  twenty- 
four  hours  and  the  amount  of  sediment. 

The  diet  should  be  restricted  in  quantity  and  certain  articles  of  food  and  drink 
should  be  avoided  altogether.  Liver,  sweetbreads,  kidneys,  smoked  or  salt  meats, 
green  fruits,  asparagus,  tomatoes,  rhubarb,  strawberries,  burgundy,  port,  sherry, 
and  champagne  are  supposed  to  be  especially  harmful. 

During  an  attack  of  renal  colic  the  pain  should  be  relieved  by  the  hypodermic 
administration  of  morphin  and  atropin  and  the  local  application  of  heat. 

Curative. — There  are  certain  cases  in  which  a  stone  may  be  suspected  strongly 
and  yet  none  can  be  positively  demonstrated.  Under  such  circumstances,  if  pallia- 
tive measures  are  without  result  and  the  patient  continues  to  suffer,  it  is  advisable 
to  do  an  exploratory  nephrotomy.  In  many  of  these  cases  no  stone  will  be  found, 
but  some  other  condition,  as  unsuspected  tuberculous  foci,  small  tumors,  etc., 
which  equally  require  surgical  treatment.  In  numerous  instances  nothing  has 
been  found  to  explain  the  pain,  but  the  symptoms  have  been  relieved  immediately. 
One  of  the  authors  has  in  mind  a  woman  who  had  recurrent  attacks  of  renal  pain. 
Stone  was  suspected,  but  could  not  be  proved  to  exist.  Palliative  treatment  was 
ineffectual.  At  length  nephrotomy  was  done  and  the  kidney  split  from  one  end  to 
the  other  in  a  futile  search  for  stone;  the  patient  was  fully  relieved  of  her  symp- 
toms. Numerous  similar  cases  have  been  reported.  They  are  probably  instances 
of  increased  tension  within  the  kidney  from  chronic  nephritis.  The  nephrotomy 
results  in  the  re-establishment  of  a  circulatory  equilibrium  and  the  patient  is  re- 
lieved. Exploratory  nephrotomy  should  never  be  performed  until  every  other  means 
to  reach  a  positive  diagnosis  has  been  tried. 

When  the  diagnosis  of  a  kidney  stone  is  positive,  the  best  treatment  in  the 
majority  of  cases  is  an  immediate  operation.  There  are  certain  conditions  which 
make  active  surgical  treatment  imperative  and  others  which  justify  its  postponement. 
Immediate  operation  is  more  of  a  necessity  in  case  the  kidney  is  infected,  for  then 
unless  prompt  relief  is  afforded  the  organ  will  be  destroyed.  When  the  stone  is 
small  and  the  kidney  is  aseptic,  operation  may  be  postponed  to  a  suitable  occasion, 
hoping  in  the  case  of  a  very  small  calculus  that  it  will  be  passed  spontaneously.  If 
there  is  some  reason  for  avoiding  a  surgical  procedure,  as  old  age,  heart  disease, 
etc.,  palliative  treatment  may  be  substituted.  As  a  rule,  however,  even  in  the 
aseptic  case  with  a  small  stone,  the  health  of  the  patient  will  be  best  conserved  by 
an  immediate  operation.  One  of  us^  reported  a  case  of  nephrectomy  for  pyoneph- 
rosis due  to  a  kidney  stone,  in  which  the  patient  had  suffered  for  three  years. 
This  type  of  case  shows  particularly  the  importance  of  an  early  diagnosis  of  cal- 
culus and  the  removal  of  the  same  by  nephrotomy  before  the  kidney  has  been 
destroyed  by  suppuration. 

'  Noble,  Charles  P.:  "Report  of  a  Case  of  Nephrectomy  for  Pyonephrosis  Due  to  Impaction 
of  a  Stone  in  the  Ureter,"  Amer.  Jour.  Obstet.,  1900,  vol  xli,  No.  3,  p.  308. 


INFLAMMATION    OF   THE    PARANEPHRIC   TISSUES.  799 

In  the  case  of  calculous  anuria  no  time  should  be  lost.  The  least  affected  kidney, 
as  far  as  can  be  determined,  should  be  immediately  exposed  and  drained. 

A  stone  may  be  removed  by  an  incision  into  the  kidney  pelvis  or  parenchyma, 
depending  upon  its  location  and  size.  If  the  kidney  is  aseptic,  the  wound  may  be 
sutured  and  the  operation  completed  without  drainage.  Such  an  ideal  course 
cannot  be  pursued  if  there  has  been  much  dilatation  of  the  kidney  pelvis  and  there 
is  any  uncertainty  about  obstruction  of  the  ureter.  If  the  kidney  has  been  dis- 
tended, even  though  the  parenchyma  seems  to  be  entirely  atrophied,  it  is  well  to 
be  satisfied  with  nephrotomy  and  drainage  until  it  has  been  demonstrated  that  the 
organ  is  useless  and  that  the  second  kidney  is  in  good  condition.  In  that  event 
a  secondary  nephrectomy  may  be  indicated.  Likewise,  if  there  is  any  doubt  that 
the  ureter  is  patulous,  it  is  better  to  drain  the  kidney  pelvis  through  the  nephrotomy 
incision.  If  there  is  no  obstruction,  the  fistula  will  almost  surely  close  spontane- 
ously. Except  in  emergency  cases,  the  functional  activity  of  each  kidney  should  be 
determined  before  operation,  so  that  primary  nephrectomy  may  be  performed  when 
indicated. 

When  the  kidney  is  infected,  the  operation  of  nephrolithotomy  should  be  fol- 
lowed by  ample  drainage.  Nephrectomy  is  never  advisable  primarily  on  account 
of  the  frequency  of  bilateral  nephrolithiasis,  unless  the  diseased  kidney  is  hopelessly 
destroyed  and  the  opposite  organ  is  known  to  be  free  from  calculi  and  functionally 
sufficient.  It  is  much  better  to  do  nephrolithotomy  (bilateral,  if  indicated)  at  first, 
and  to  follow  this,  if  occasion  requires,  with  nephrectomy. 

For  details  of  the  operation  of  nephrolithotomy  and  nephrectomy  see  pages  834 
and  836. 

INFLAMMATION  OF  THE  PARANEPHRIC  TISSUES. 

By  paranephritis  (Kiister),  perinephritis  (Rayer),  or  epinephritis  (Israel)  is 
understood  an  inflammatory  affection  of  the  fatty  capsule  of  the  kidney.  There 
are  three  forms:  the  fibrosclerotic,  the  lipomatous,  and  the  suppurative  or  phleg- 
monous. 

Fibroscler otic. —In  the  fibrosclerotic  form  there  is  a  transformation  of  the  fatty 
capsule  into  a  thick,  hard,  sometimes  cartilage-like  tissue,  closely  fused  with  the 
fibrous  capsule  of  the  kidney  and  robbing  that  organ  of  its  normal  mobility.  This 
condition  does  not  often  present  itself  as  a  clinical  entity,  but  it  is  found  in  connec- 
tion with  pyelonephritis,  pyonephrosis,  and  nephrolithiasis.  It  presents  an  in- 
superable obstacle  at  times  to  the  ordinary  form  of  nephrectomy.  The  kidney  with 
its  encasement  of  fibrosclerotic  tissue  cannot  be  freed  from  surrounding  structures 
without  great  danger  to  the  important  neighboring  viscera  or  to  the  great  blood- 
vessels. The  diaphragm,  the  pleura,  the  vena  cava,  and  the  colon  may  be  in  danger. 
If  nephrectomy  is  indicated  in  fibrosclerotic  paranephritis,  the  subcapsular  opera- 
tion should  be  selected.  (See  page  836.)  The  fibrosclerotic  tissue  may  produce 
considerable  enlargement  of  the  kidney.  With  this  increase  of  size  there  is  usually 
some  pain  and  tenderness. 


800  SURGERY   OF   THE   KIDNEY. 

Lipomatous. — In  the  lipomatous  form  there  is  a  great  hypertrophy  of  the  fatty 
capsule,  which  occasionally  grows  to  the  dimensions  of  a  tumor.  The  hyperplasia 
affects  either  the  entire  capsule  of  the  kidney  or  a  part  of  it,  being  confined  to 
certain  areas,  particularly  the  hilus  or  both  poles.  I^ocalized  forms  give  the  impres- 
sion of  a  tumor  formation  more  than  the  others.  The  lipomatous  tissue  may  also 
surround  the  ureter.  Such  an  irritation-hyperplasia  of  the  fatty  capsule  is  caused 
by  chronic  inflammatory  kidney  processes,  especially  nephrolithiasis,  and  is  often 
associated  with  atrophy  of  the  parenchyma  and  sclerosis  of  the  interstitial  substance 
of  the  kidney.  The  atrophied  kidney  forms  a  nucleus  for  the  fatty  mass  which 
surrounds  it  and  penetrates  it  from  the  hilus,  the  fat  occupying  the  place  of  the 
destroyed  parenchyma. 

Phlegmonous. — The  suppurative  or  phlegmonous  form  of  paranephritis  may 
arise  either  in  the  capsule  or  it  may  extend  to  the  capsule  from  contiguous  parts. 
Phlegmons  arising  in  the  capsule  may  be  due  to  perforating  wounds  with  infection 
from  the  surface  or  from  the  intestines,  or  to  the  penetration  of  the  capsule  by 
foreign  bodies  entering  from  the  bowel,  as  needles,  fish-bones,  etc.  Blows,  sprains, 
or  falls  may  produce  a  phlegmon,  presumably  by  the  formation  of  a  hematoma 
which  is  subsequently  infected  by  bacteria  transported  in  the  blood  from  some 
other  part  of  the  body.  Or  these  injuries  may  be  associated  with  a  slight  cortical 
lesion  of  the  kidney  through  which  micro-organisms  and  urine  may  escape.  Metas- 
tatic phlegmonous  inflammation  of  this  area  may  occur  in  the  course  of  measles, 
variola,  typhoid  fever,  etc. 

Phlegmonous  paranephritis  is  usually  secondary  to  a  disease  of  the  neighboring 
organs  or  tissues.  The  kidney  is  the  most  frequent  source  of  infection.  Other 
sources  are  found  in  the  inflammatory  diseases  of  the  urinary  passages  and  of  the 
retroperitoneal  fatty  tissue  (following  parametritis,  prostatitis,  and  appendicitis). 
The  suppurative  process  may  invade  the  paranephric  tissue  by  a  direct  erosion  of 
the  fibrous  capsule  of  the  kidney,  or  the  infection  may  be  conveyed  through  the 
lymphatic  channels,  there  being  no  involvement  of  tke  kidney  cortex.  Infection 
may  be  carried  also  by  the  lymphatics  from  the  lower  ureter  without  any  involve- 
ment of  the  kidn&y. 

Israel  says  that  since  it  is  more  widely  known  that  nephritis  may  exist  without 
albuminuria,  fewer  cases  of  phlegmonous  paranephritis  of  unexplained  origin  are 
reported.  While  Kiister  in  two  hundred  and  thirty  cases  found  sixty-seven,  i.  e., 
29.1  per  cent.,  of  doubtful  origin,  Israel  had  but  three  in  his  own  forty-three  observa- 
tions (6.9  per  cent.)  in  which  he  could  find  no  cause.  In  Israel's  forty-three  cases, 
thirty-four  arose  from  disease  of  the  kidney,  six  from  gonorrheal  affections  of  the 
urinary  passages,  three  from  unknown  causes. 

Pathologic  Anatomy. — In  the  great  majority  of  cases  the  abscess  points  toward 
the  loin  and  forms  a  visible  and  easily  palpable  tumor  in  this  region.  There  are 
two  points  at  which  the  pus  tends  to  break  through  the  lumbar  fascia  and  muscles. 
The  first  of  these  is  Petit's  triangle,  bounded  by  the  crest  of  the  ilium,  the  anterior 
border  of  the  latissimus  dorsi,  and  the  posterior  border  of  the  external  oblique.     The 


INFLAMMATION    OF   THE    PARANEPHRIC    TISSUES.  801 

second  is  just  below  the  twelfth  rib,  at  the  outer  border  of  the  erector  spinse. 
Abscesses  appearing  at  this  point  penetrate  the  latissimus  dorsi.  Occasionally, 
however,  instead  of  breaking  through,  they  pass  down  the  anterior  surface  of  the 
muscle  to  Petit's  triangle. 

An  abscess  may  also  gain  access  to  the  thorax,  traveling  along  the  quadratus 
lumborum  through  the  slit  which  the  external  arcuate  ligament  of  the  diaphragm 
forms,  or  along  the  sheath  of  the  psoas  muscle.  In  this  way  pus  may  gain  entrance 
to  the  pleura  or  to  the  lung  itself.  An  empyema  or  an  abscess  of  the  lung  may  result. 
The  pus  may  remain  within  the  diaphfagm,  forming  an  endophrenic  collection, 
or  it  may  travel  downward  back  of  the  peritoneum  along  the  ureters  to  the  pelvis, 
or  along  the  sheath  of  the  iliopsoas  muscles  to  Poupart's  ligament.  The  abscess 
may  find  its  way  through  the  great  sacrosciatic  foramen  to  the  gluteal  region.  It 
may  break  into  the  ureter,  the  bladder,  the  male  urethra,  the  rectum,  or  the  scrotum. 
In  two  hundred  and  thirty  cases  of  paranephritis  there  were  thirty-four  abscesses 
which  evacuated  themselves  into  neighboring  or  far-distant  organs — eighteen  into 
the  pleura,  eleven  into  the  bowel,  two  into  the  peritoneal  cavity,  two  into  the  bladder 
and  vagina,  and  one  into  the  bladder  alone. 

Symptoms. — The  lipoma tous  and  the  fibrosclerotic  forms  of  paranephritis 
may  have  few  symptoms  in  themselves  and  may  escape  the  observation  of  a  phy- 
sician. Occasionally,  however,  there  is  a  feeling  of  dull  pressure  in  the  affected 
area,  and  there  may  be  stiffness  of  the  back,  an  inclination  of  the  body  to  the  affected 
side,  and  some  flexion  and  abduction  of  the  thigh. 

In  the  suppurative  cases  the  symptoms  arising  from  the  paranephritic  process 
may  be  masked  by  those  of  a  preceding  and  associated  kidney  stone,  pyelone- 
phritis, pyonephrosis,  etc.  The  typical  symptoms  of  a  paranephritis  are  seen  in  those 
cases  in  which  the  fatty  capsule  is  the  part  principally  affected  and  there  is  no  pro- 
nounced kidney  disease. 

The  disease  may  develop  slowly  and  insidiously  or  very  suddenly  and  without 
any  warning.  The  early  symptoms  are  pain,  chills,  and  sweats.  Usually  this  is 
followed  by  more  or  less  fever,  although  there  are  cases  in  which  pyrexia  does  not 
occur  for  a  long  time.  The  fever  is  usually  remittent  with  evening  exacerbations. 
Anorexia,  nausea,  vomiting,  and  emaciation  occur.  The  patient  presents  a  wasted, 
anemic  appearance,  a  condition  spoken  of  by  the  older  writers  as  "phthisis  renalis." 
If  the  paranephritis  follows  urinary  extravasation  into  the  fatty  capsule  and  is 
gangrenous,  there  may  be  a  profound  septic  condition.  In  connection  with  these 
more  or  less  general  symptoms  of  deep-seated  suppuration,  there  are  particular 
symptoms  which  draw  attention  specifically  to  the  loin. 

The  pain  is  more  or  less  constant  in  the  lumbar  region.  It  may  be  a  feeling  of 
dull  uneasiness  or  an  actual  ache,  or  darting  or  pricking  in  character  and  paroxysmal, 
shooting  into  the  axilla,  breast,  hypogastrium,  thigh,  and  external  genitalia.  The 
pain  is  increased  by  bodily  motion  and  deep  inspiration,  so  that  there  is  usually 
limitation  of  the  respiratory  movements  and  the  patient  inclines  the  body  toward 
the  affected  side.     The  lumbar  and  abdominal  muscles  on  the  aftected  side  are 

VOL.  II — 51 


802  SURGERY  OF  THE  KIDNEY. 

rigid  and  the  loin  is  acutely  sensitive  to  pressure  at  two  points  especially;  viz.,  just 
below  the  twelfth  rib  and  over  the  area  of  Petit's  triangle.  There  may  be  contrac- 
tion of  the  psoas  muscle.  The  patient  walks  with  a  limp,  the  trunk  is  fixed,  the 
thigh  is  adducted,  and  the  body  bent  forward  and  toward  the  diseased  side. 

There  may  be  no  more  than  a  fullness  in  the  loin,  of  such  small  dimensions  that 
careful  measurements  and  comparison  of  the  two  sides  of  the  body  are  required  for 
its  demonstration.  Usually,  however,  there  is  a  w^ell-marked  tumor,  which  occupies 
the  lumbar  fossa  and  has  no  respiratory  mobility.  It  has  ill-defined  outlines  and 
merges  with  the  surrounding  tissues.  There  is  no  enlargement  of  the  abdomen 
unless  the  tumor  is  of  great  size.  There  is  dullness  over  the  tumor  in  the  loin,  and 
this  dullness  is  continuous  above  with  that  of  the  liver  or  the  spleen. 

The  abscess  may  point  in  Petit's  triangle  or  just  below  the  twelfth  rib.  Before 
this  occurs  fluctuation  may  be  evident.  When  the  collection  of  pus  burrows  beneath 
the  diaphragm,  it  may  be  discharged  into  the  pleura  (empyema),  the  lung  (abscess), 
or  a  bronchus.  Any  involvement  of  the  chest  is  usually  accompanied  by  dyspnea 
and  cough;  penetration  of  a  bronchus  is  followed  by  the  expectoration  of  pus. 
Evacuation  into  the  bowel  is  preceded  by  griping  pain  and  a  desire  to  defecate. 
If  the  pus  breaks  into  the  kidney  or  the  ureter,  there  are  symptoms  of  renal  colic, 
mild  or  severe. 

As  paranephritis  usually  depends  upon  an  antecedent  kidney  lesion,  some 
urinarv  alteration  will  usually  be  foimd.  This  need  not  produce  gross  changes  in 
the  tirine  and  there  may  be  no  reaction  to  the  tests  for  albumin.  Israel  remarks 
that  urine  which  looks  normal  and  has  a  negative  reaction  for  albumin  by  no  means 
excludes  kidney  disease.  His  own  practice  is  to  let  the  urine  stand  in  a  conical  glass 
for  twelve  hours;  at  the  end  of  that  time  the  lower  stratum  containing  the  sediment 
is  centrifugated  and  examined  microscopically.  If  red  blood-corpuscles,  shadow 
cells,  and  granular  or  hyaline  casts  are  found,  it  may  be  taken  as  presumptive 
evidence  of  a  kidney  lesion.  A  small  amount  of  albumin  and  occasional  hyaline 
casts  may  be  due  entirely  to  the  general  influence  of  the  suppuration  on  the  kidney, 
exactly  as  if  the  disease  were  located  in  another  part  of  the  body.  IMore  advanced 
urinarv  alterations  may  occur  from  actual  secondary  involvement  of  the  kidney  in 
the  inflammatory  process. 

Diagnosis. — Xon-suppurative  paranephritis  may  be  confused  with  lumbago, 
lumbar  neuralgia,  and  renal  colic.  White  and  ^Martin  draw  attention  to  the  fact 
that  some  of  the  infectious  diseases  in  their  early  stage  resemble  paranephritis. 
Among  them  may  be  mentioned  influenza,  smallpox,  and  cerebrospinal  fever. 
Appendicitis,  caries  of  the  vertebra,^nd  coxalgia  may  be  mistaken  for  paranephritis. 
Splenic  and  hepatic  tumors,  fecal  impaction,  cancer,  tubercle  or  tumors  of  the  kid- 
ney, w^ill  need  to  be  differentiated.  The  enlargement  due  to  paranephritis  lacks 
the  definite  outline  of  a  kidney  tumor;  it  distends  the  loin  more  than  the  abdomen 
and  has  no  respiratory  mobility.  Paranephritis  lacks  the  tenderness  on  percussion 
and  the  relief  of  symptoms  by  extension  found  in  caries  of  the  vertebra.  The 
symptoms  directly  referable  to  the  hip-joint,  seen  in  coxalgia,  are  absent  in  para- 


TUMORS    OF   THE    KIDNEY.  803 

nephritis.  Appendicitis  is  usually  more  acute  and  less  apt  to  be  preceded  by  symp- 
toms referable  to  the  kidney.  The  greatest  tenderness  is  over  McBurney's  point, 
while  in  paranephritis  it  is  in  the  loin  below  the  twelfth  rib.  ^^^lether  or  not  a 
kidney  lesion  exists  which  would  predispose  to  paranephritis,  such  as  stone,  pyo- 
nephrosis, or  pyelonephritis,  is  of  the  greatest  importance  from  a  diagnostic  stand- 
point. 

Prognosis. — This  depends  upon  the  cause.  Cases  resulting  from  trauma  are 
usually  followed  by  prompt  recovery  after  a  free  incision  and  evacuation  of  the  pus. 
When  the  lesion  follows  kidney  disease,  the  prognosis  is  less  favorable.  Of  thirty- 
nine  cases  of  suppurative  paranephritis  recorded  by  Israel,  twelve  ended  in  death. 
But  eleven  of  these  were  numbered  among  nineteen  cases  in  which  the  paranepliric 
lesion  was  secondary  to  marked  lesions  of  the  kidney — calculus,  etc.  In  twenty 
other  cases  following  less  marked  kidney  disease  or  affections  of  the  lower  urinarv 
passages  there  was  but  one  death.  In  two  hundred  and  thirty  cases  collected  bv 
Ktister,  one  hundred  and  forty-five  were  cured;  six  recovered  except  for  a  persisting 
fistula;  seventy-nine  died. 

The  treatment  makes  a  great  difference  in  the  prognosis.  An  early  diagnosis 
and  prompt,  well-directed  treatment  are  conducive  to  good  results.  The  danger 
rises  with  the  gravity  of  the  cause  and  a  temporizing  or  uncertain  attitude  of  the 
physician.     Pregnancy  has  an  unfavorable  influence. 

Treatment. — \^^iile  the  disease  is  in  its  early  stage  and  before  the  diagnosis 
is  certain,  the  treatment  should  be  expectant.  A  liquid  restricted  diet,  rest  in  bed, 
hot  or  cold  applications  to  the  painful  area,  and  a  thorough  evacuation  of  the  bowels 
are  in  order.  Morphin  in  small  doses  may  be  used  to  relieve  pain  and  urinary 
diluents  should  be  prescribed.  As  soon  as  the  diagnosis  of  suppurative  parane- 
phritis is  made,  immediate  incision  is  indicated.     (See  page  823.) 


TUMORS  OF  THE  KIDNEY. 

Renal  tumors  are  not  very  frequent.  Kiister  reports  fifteen  tumors  of  the  kidney 
occurring  among  19,934  patients.  Israel  had  sixty-eight  cases  and  performed  an 
operation  in  forty-three  (65  per  cent.).  Operation  for  kidney  tumors  formed  14 
per  cent,  of  all  his  kidney  operations. 

Of  seven  hundred  and  seventy-three  tumors  collected  by  Kiister,  six  hundred 
and  fifty-two  were  of  the  kidney,  seventy  of  the  capsule,  and  fifty-seven  of  the 
adrenals. 

They  are  rather  more  frecjuent  in  men  than  in  women,  but  they  are  more  often 
inoperable  in  women.  The  reason  for  this  fact  is  that  the  earlier  symptoms  of  a 
renal  new-growth  (hematuria  and  tumor)  do  not  attract  so  much  attention  in  women 
as  they  do  in  men. 

The  most  frequent  tumors  of  the  kidney  are,  in  order,  hypernephroma,  papillary 
cystoma,  endothelioma,  sarcoma,  true  carcinoma,  and  adenoma. 

Malignant  renal  tumors  aft'ect  especially  the  young  and  the  old.     They  do  not 


804 


SURGERY   OF   THE   KIDNEY. 


occur  during  the  period  when  tuberculosis  is  especially  common.  Sixty-one  of 
Israel's  sixty-eight  cases  occurred  between  fifty  and  eighty  years;  thirty-nine  of 
Morris's  one  hundred  and  forty-eight  cases  (collected)  occurred  under  the  age  of  five. 


KIDNEY  TUMORS. 
The  tumors  which  affect  the  kidney  and  the  kidney  region  are  indicated  by  the 
following  tables : 

Solid. 

angioma 

lymphangioma 
I   osteoma 
I   enchondroma 
\   fibroma 

adenoma 

lipoma 

lipofibroma 

lipomyxoma 

carcinoma 


Kidney . 


Benign . 


.  Malignant. 


mixed  tumors. 


round-cell 

spindle-cell 

mixed-cell 

perithelioma 
[  endothelioma 
/  embryonic  adenosarcoma 
\  teratoma 


Pelvis  and  Ureter. 


Suprarenal  glands Malignant 


Pararenal . 


hypernephroma 

Benign (  P^PiHoma 

'^  1^  myxoma 

f  papillary  carcinoma 
squamous  epithelioma 
Malignant.  .   \   angiosarcoma 

I   lymphatic  endothelioma 

[  rhabdomyoma 

/  hypernephroma 

\  carcinoma 

(  lipoma 
Benign -j   fibroma 

■^  myxoma 

f  hypernephroma 
Malignant.  .    \   sarcoma 

[  mixed  tumors 

Cystic. 

(  simple  cysts 
Benign )   polycystic  disease 

I   benign  adenocystoma 

[  echinococcus  cysts 
Malignant malignant  adenocystoma 

f  blood  cysts — trauma 

I   epithelial  cysts  from  snared-ofT  portions  of  kidney  pelvis 
.  Benign {  lymph  cysts 

I   Wolffian  body  cysts 

[  dermoid  cysts 

Solid  Tumors  of  the  Kidney ;  Benign. — Fibroma. — Pure  fibromata  are  very 
rare.     Schede  asserts  that  there  is  none  on  record. 

Adenoma. — Adenoma  is  found  oftenest  in  chronically  inflamed  and  contracted 
kidneys  and  may  reach  a  considerable  size.  There  is  a  papillary  form  which  some- 
times becomes  malignant. 


Kidney . 


Pararenal . 


KIDNEY   TUMORS.  805 

Lipoma. — A  pure  lipoma  is  very  rare.  Lipomatous  tumors  are  usually  mixed 
tumors  and  contain  myxomatous  fibers  and  smooth  muscle  cells.  They  frequentl}' 
become  sarcomatous. 

The  other  benign  tumors  of  the  kidney  are  of  scientific  interest  only,  as  they 
never  reach  a  large  size  or  produce  symptoms. 

Fibroma,  lipoma,  and  adenoma,  if  pure,  usually  give  rise  to  few  symptoms. 
After  they  are  large  enough  to  produce  a  recognizable  tumor,  the  patient  may  com- 
plain of  some  weight  or  pressure  in  the  renal  region.  When  they  attain  such  a  size, 
they  should  be  removed  from  the  kidney  by  resection,  if  that  is  possible;  otherwise, 
nephrectomy  is  indicated. 

Malignant  Tumors  of  the  Kidney. — Carcinoma. — Carcinoma  is  one  of  the 
less  frequent  tumors  of  the  kidney.  There  are  three  forms:  (a)  papillary;  (h) 
nodular,  circumscribed  or  adenomatous;    (c)  infiltrating. 

The  papillary  is  an  advanced  stage  of  a  malignant  adenocystoma,  or  it  begins 
as  a  papillary  tumor  in  the  pelvis  of  the  kidney.  The  nodular  or  the  adenomatous 
cancer  begins  in  the  cortex;  it  may  be  the  offspring  of  a  simple  adenoma.  It 
exhibits  an  alveolar  arrangement.  The  infiltrating  cancer  starts  in  the  neighbor- 
hood of  the  pelvis  and  grows  toward  the  cortex.  It  is  cancerous  from  the  onset 
and  shows  little  alveolar  structure.  It  may  destroy  the  kidney  without  producing 
any  increase  in  size  or  alteration  of  form.  Hematuria  may  be  absent  in  the  nodular 
form.     There  is  very  much  that  is  obscure  in  the  histogenesis  of  renal  carcinoma. 

Sarcoma. — Sarcomata  may  arise  from  the  connective  tissue  of  the  kidney  substance 
or  from  the  submucous  connective  tissue  of  the  calyces  and  the  kidney  pelvis. 
Histologically  they  may  be  round-,  spindle-,  or  mixed-cell,  and  they  may  be  classed 
as  simple  angiosarcoma,  vascular  endothelioma,  lymphatic  endothelioma,  and  peri- 
vascular sarcoma  or  perithelioma.  Most  of  the  endothelial  and  the  perithelia] 
forms  that  have  been  described  are  really  hypernephromas.  The  sarcomatous 
tissue  may  undergo  myxomatous  change,  resulting  in  a  myxosarcoma.  Sarcomata 
containing  bone,  muscle,  fat,  and  epithelium  belong  to  the  embryonal  or  mixed 
tumors. 

Mixed  Tumors. — Embryonic  Adenosarcoma. — These  tumors  occur  most  often 
in  childhood  and  infancy.  They  are  composed  of  a  mixture  of  glandular  and  of 
embryonal  connective  tissue.  At  times  also  they  contain  smooth  and  striated 
muscle  cells.  They  have  been  named  carcinoma,  sarcoma,  sarcomatous  carcinoma, 
adenosarcoma,  adenochondrosarcoma,  myosarcoma,  and  rhabdomyosarcoma,  ac- 
cording to  the  tissues  which  they  contain.  The  tumors  are  very  rapid  in  growth, 
enlarging  in  three  or  four  months  from  the  size  of  a  fist  to  a  tumor  filling  the  ab- 
domen.    They  may  destroy  or  only  partially  invade  the  kidney.^ 

Metastasis  occurs  by  way  of  the  blood-vessels  to  the  liver,  the  lungs,  the  retro- 
peritoneal glands,  the  second  kidney,  the  intestines,  and  the  pancreas.  They  very 
often  cause  a  localized  peritonitis  and  become  adherent  to  the  abdominal  organs. 
Ascites  may  be  present.  The  average  weight  is  from  five  to  fifteen  pounds,  but  in 
1  Holt,  L.  Emmet:    "The  Diseases  of  Infancy  and  Childhood,"  1905 


806  SURGERY    OF   THE   KIDNEY. 

one  case  the  tumor  weighed  thirty -six  pounds.  The  presence  of  a  tumor  is  usually 
the  first  symptom.  In  nineteen  out  of  fifty  cases  occurring  in  children,  hematuria 
was  noted  before  the  tumor  appeared.  The  only  treatment  is  operation;  this 
should  be  performed  as  soon  as  the  condition  is  diagnosed. 

The  prognosis  of  these  cases  has  been  almost  uniformly  bad.  The  only  hope  lies 
in  an  early  operation.    Most  cases  are  ultimately  fatal,  but  cures  have  been  reported. 

The  proper  treatment  is  immediate  nephrectomy.  Bean^  gives  the  percentage 
of  permanent  cure  at  5  or  6  per  cent.  The  disease  is  always  fatal  if  let  alone. 
From  observations  of  his  own  and  an  examination  of  the  literature,  Le  Conte^  con- 
cludes, in  relation  to  the  treatment  of  these  tumors,  that  with  modern  methods  the 
immediate  mortality  should  be  reduced  to  15  per  cent,  or  even  lower.  Operation 
certainly  prolongs  life.  The  percentage  of  cases  which  will  go  three  years  or  more 
without  a  sign  of  recurrence  (the  so-called  cures)  will  be  very  greatly  increased, 
if  the  physician  can  make  an  early  diagnosis  and  secure  an  immediate  operation. 
Even  when  the  ultimate  result  is  fatal,  an  operation  relieves  the  suffering  of  the 
patient  and  makes  death  less  painful. 

Hi/pernephronia. — This  is  the  most  frequent  malignant  timior  of  the  kidney. 
Israel  had  fifteen,  possibly  seventeen  cases,  in  forty-three  malignant  tumors  of  the 
kidney. 

Hypernephroma  is  defined  by  Ellis^  as  a  tumor  arising  from  adrenal  tissue, 
whether  in  the  suprarenal  gland  or  in  aberrant  particles  known  as  renal  rests. 
Primary  hypernephroma  involves  the  kidney  in  96  per  cent,  of  reported  cases;  it 
may,  however,  occur  in  widely  different  situations.  The  possibility  of  hyperneph- 
roma occurring  elsewhere  than  in  the  kidney  or  the  adrenals  is  apparent  from  a 
study  of  the  development  of  these  glands.  The  adrenals  and  the  sexual  organs  are  so 
intimately  related  in  their  development  that  portions  of  the  first  may  easily  be 
displaced  into  the  neighborhood  of  the  second.  Ellis  quotes  Radasch  as  saying 
that  adrenal  rests  have  been  found  in  the  kidney,  the  liver,  the  perirenal  tissues, 
the  solar  and  renal  plexuses,  the  mesentery,  the  region  of  the  internal  abdominal 
ring,  the  inguinal  canal,  the  spermatic  cord,  the  epididymis  and  testicle,  the  broad 
ligament,  and  the  fundus  of  the  uterus. 

Hypernephromas  of  the  kidney  are  usually  single.  According  to  Ellis,  whom 
we  quote  freely,  the  frankly  malignant  tumors  vary  in  size  from  a  pea  to  a  child's 
head.  The  small  ones  are  almost  invariably  confined  to  the  renal  cortex.  Large 
tumors  project  from  the  surface  of  the  kidney  and  extend  inward,  destroying  the 
renal  structure  until  they  reach  the  pelvis,  which  may  be  obliterated  by  pressure, 
but  is  seldom  actually  penetrated.  -"The  external  surface  of  the  tumor  is  lobulated. 
The  color  is  usually  grayish-red  or  yellow,  the  latter  predominating;  but  often  there 

1  Bean,  J.  W.:  "Two  Rare  Forms  of  Tumor  of  the  Kidnev,"  N.  W.  Med..  1903,  vol.  I,  No. 
1,  pp.  11-16. 

^  LeConte,  Robert  G.:  "Two  Cases  of  Nephrectomy  for  Sarcoma  of  the  Kidney  in  Children 
with  Operative  Recoveries,"  Therapeutic  Gazette.  1902,  xviii,  p.  577. 

^  Ellis,  E.  G.,  with  W.  W.  Keen  and  G.  E.  Pfahler:  "On  Hypernephroma,"  Amer.  Med., 
1904,  vol.  viii,  No.  25,  p.  1039. 


KIDNEY   TUMORS. 


807 


are  brown  or  bluish  or  even  black  areas  through  the  presence  in  the  tumor  of  small 
or  massive  hemorrhages.  The  tumor  may  be  firm,  but  in  many  of  the  larger  growths 
the  projecting  masses  are  softened,  in  some  instances  being  almost  cyst-like  in 
consistency.  Incision  of  the  tumor  reveals  surfaces  corresponding  closely  to  the 
external  appearance  in  color  and  in  lobulation.  Masses  within  alveoli  formed 
by  the  fibrous  stroma  may  be  so  soft  as  to  project  and  even  detach  themselves 
from  the  surrounding  tissue.  The  tumor  is  generally  sharply  outlined  from  any 
remaining  renal  structure  by  a  complete  band  of  firm  fibrous  structure  (Fig.  848). 
Hemorrhages  into  the  tumor  are  exceedingly  common,  and  areas  of  softening  due  to 
degenerative  changes  are  also  frequently  present." 

All  hypernephromas  may  be  regarded  as  potentially  malignant.  Apparently 
benign  hypernephromas  are  capable  of 
giving  rise  to  metastases  larger  than  the 
primary  growth.  Metastases  are  most 
frequently  found  in  the  lungs,  liver,  and 
bones,  although  almost  any  tissue  may  be 
invaded. 

Symptoms. — There  are  three  chief 
symptoms  of  malignant  tumors  of  the 
kidney:  Hematuria,  pain,  and  the  solid 
growth  itself.  Cachexia  and  metastases 
appear  in  the  later  stages.  The  presence 
of  a  renal  tumor  is  the  only  diagnostic 
certainty.  In  many  cases  its  value  as  a 
diagnostic  symptom  is  lessened,  for  when 
the  growth  is  found,  the  case  is  inoperable; 
nevertheless,  enlargement  of  the  kidney  is 
sometimes  the  only  early  evidence  of  the 
disease. 

Hematuria  is  the  most  common  initial 
symptom.  It  occurs  with  or  without 
renal  colic,  appearing  in  more  than  70  per 

cent,  of  Israel's  cases  without  any  warning  Fig.  848.— Hypernephroma  of  Kidney. 

in  a  previously  healthy  patient.     In  the 

other  30  per  cent,  of  cases  there  were  preliminary  indications,  such  as  a  feeling  of 
pressure  in  the  kidney  region,  disturbance  of  the  general  health,  anorexia,  emacia- 
tion, a  feeling  of  weakness,  perspiration  or  indigestion,  preceding  the  onset  of 
hematuria. 

Acute  pain  in  both  kidney  regions,  associated  with  a  slight  elevation  of  tempera- 
ture and  albuminuria,  were  the  earlier  symptoms  in  one  instance  recorded  by  Israel. 
As  a  rule,  cachexia  does  not  appear  until  the  disease  is  far  advanced  (except  in  the 
rapid  growing  tumors  of  children),  and  fever  does  not  often  occur  (five  times  in 
Israel's  cases). 


SURGERY    OF   THE    KIDNEY. 

Hematuria  occurred  in  92.1  per  cent,  of  Israel's  series  and  was  the  first  symptom 
in  70  per  cent.  It  may  appear  early  in  the  life  of  the  tumor,  when  the  growth  is  no 
larger  than  a  cherry,  as  happened  in  three  cases.  The  value  of  hematuria  as  an 
early  symptom  and  the  failure  to  appreciate  its  significance  is  shown  by  four  of 
Israel's  cases,  in  which  hematuria  had  been  observed  for  eleven  and  a  half,  ten, 
eight,  and  six  years,  before  the  operation.  In  half  of  the  cases  the  renal  origin  of 
the  hemorrhage  was  indicated  by  colic  or  by  a  disagreeable  sense  of  pressure  in  the 
loins — on  the  particular  side  in  45.6  per  cent.  Hemorrhage  is  to  some  extent 
independent  of  activity  or  repose.  Although  riding  over  a  rough  road  increases  it 
and  a  fall  on  the  buttocks  or  the  lifting  of  a  heavy  weight  are  responsible  at  times 
for  its  onset,  hematuria  is  usually  intermittent  and  may  come  on  without  apparent 
cause  while  the  patient  is  asleep. 

The  urine  may  have  the  color  of  fresh  blood.  It  usually  varies  in  appearance 
from  almost  pure  blood  to  a  straw-colored  serum.  Grossly  the  urine  may  be  clear 
and  contain  coagula.  Worm-like  clots  10  cm.  long  are  quite  significant  of  coagula- 
tion within  the  ureter.     Shorter  clots  than  this  may  be  formed  in  the  urethra. 

Israel  describes  worm-like  bodies  in  the  urine,  which  he  believes  are  almost 
pathognomonic  of  a  malignant  tumor.  They  usually  occur  in  faintly  bloody  or 
clear  urine,  and  are  reddish,  faint  yellow,  or  white  in  color,  occasionally  somewhat 
transparent.  They  are  about  the  size  of  maggots  or  even  larger,  up  to  2  cm.  in 
length  and  from  2  to  2.5  mm.  in  breadth.  jMicroscopically  they  consist  of  a  fibrin- 
ous ground  substance,  in  which  red  blood-cells,  shadow  corpuscles,  leukocytes,  fat 
droplets,  and  swollen  epithelium  are  embedded.  They  are  formed  after  the  manner 
of  a  stalactite  from  tumors  which  project  into  the  kidney  pelvis. 

The  urine  may  not  look  bloody,  and  yet  red  blood-cells  are  found  on  centri- 
fugation.  The  urine  occasionally  appeared  clear  in  forty-six  of  Israel's  series, 
but  in  80  per  cent,  of  them  the  microscope  showed  red  blood-cells  and  shadow- 
corpuscles.  This  ratio  he  considers  too  low,  for  cases  are  included  which  were 
treated  at  a  time  when  centrifugation  was  not  customary.  There  were  but  two  cases 
in  his  entire  experience  in  which  no  abnormal  constituents  were  found  in  the  urine. 
A  few  leukocytes,  large  clumps  of  fat  droplets,  or  large  fatty  degenerated  cells  were 
commonly  present.  Rarely  there  were  casts  and  albumin  in  varying  amount. 
Blood  casts  were  found  in  but  two  cases,  and  both  times  they  came  from  the  second 
kidney.  Polyuria  was  usual.  Sometimes  particles  or  shreds  of  the  tumor  were 
passed  in  the  urine. 

Pain  may  be  the  first  indication  of  a  kidney  tumor.  It  varies  from  renal  colic 
to  a  feeling  of  dull  distress  in  the  kidney  region,  accentuated  by  the  pressure  of  the 
clothing  or  by  unusual  activity.  The  pain  may  be  continuous  or  recurrent.  It  is 
felt  in  the  loins  or  in  the  buttocks  radiating  into  the  hips.  Neuralgic  pains  are 
observed  occasionally  along  the  distribution  of  the  ilio-hypogastric  and  the  ilio- 
inguinal nerves.  In  about  60  per  cent,  of  Israel's  cases  there  was  pain  which  indi- 
cated the  affected  side. 

Edema  of  the  legs  from  pressure  of  the  tumor  on  the  iliac  veins  or  the  inferior 


KIDXEY   TUMORS.  809 

vena  cava  may  occur.  There  may  be  intestinal  disturoance  or  symptoms  resembling 
those  of  chronic  gastric  catarrh.  The  heart  may  be  affected.  There  may  be  hyper- 
trophy of  the  left  ventricle,  just  as  there  is  in  contracted  kidney.  A  blowing  murmur 
coincident  with  the  systole  of  the  heart  may  be  heard  and  felt  over  the  tumor. 

Varicocele  of  the  affected  side  is  said  to  be  one  of  the  objective  indications  of  a 
kidney  tumor.  Israel  never  observed  it  in  small  tumors  and  in  large  ones  it  was 
frequently  absent. 

Unless  the  tumor  is  large  enough  to  interfere  with  the  movements  of  the  dia- 
phragm, dyspnea  is  usually  indicative  of  a  pulmonary  metastasis. 

Palpation  of  a  kidney  the  seat  of  a  tumor  may  reveal  a  nodule  projecting  from 
the  surface,  a  smooth  symmetric  enlargement  of  the  organ,  or  a  lower  pole  that  is  pal- 
pable with  unusual  ease;  the  latter  phenomenon  being  due  to  a  tumor  of  the  upper 
half  of  the  kidney  which  displaces  the  lower  pole  doT\Tiward.  Tumors  are  more 
easily  palpable  when  they  occur  at  the  lower  pole  on  the  anterior  surface  or  on  the 
convex  border.  Palpation  is  much  less  difficult  if  the  kidney  is  abnormally  movable 
and  can  be  freely  pushed  about. 

The  best  position  for  the  patient  during  palpation  of  the  kidney  is  on  the  healthy 
side  half-way  between  a  dorsal  and  a  lateral  posture,  so  that  the  frontal  plane  of  the 
body  forms  an  angle  of  45  to  50  degrees  with  the  surface  of  the  table.  The  spine 
should  not  be  bent  forward  or  backward,  for  this  either  puts  the  abdominal  muscles 
on  the  stretch  or  narrows  the  ileocostal  space.  A  correct  position  will  be  furthered 
by  turning  the  pelvis  a  little  toward  the  table  after  the  half -lateral  position  is  taken. 
^Mien  the  position  is  correct,  there  will  appear  under  the  ribs  of  the  diseased  side 
a  slight  sinking  in  and  the  belly  wall  in  its  neighborhood  will  be  relaxed.  To 
estimate  a  symmetric  increase  in  the  size  of  the  kidney  a  dorsal  position  is  the  most 
satisfactory. 

The  tumor  was  palpable  in  sixty-two  of  Israel's  sixty-eight  cases.  In  forty-one 
cases  unevenness  of  the  surface  of  the  kidney  and  knobby  prominences  were  recog- 
nized. Kiister  reports  that  of  three  hundred  and  seventy-nine  cases  of  kidney 
tumor  in  adults,  the  condition  was  palpable  in  but  two  hundred  and  thirty. 

Diagnosis. — ^^lalignant  tumor  of  the  kidney  in  its  early  stages  must  be  differ- 
entiated from  tuberculosis  and  nephrolithiasis.  Carcinoma  of  the  colon  and  pan- 
creatic cyst  may  bear  some  resemblance.  A  skiagraphic  examination  of  the 
diseased  organ  and  the  injection  of  guinea-pigs  with  urine  from  the  affected  side 
will  often  be  required  to  exclude  kidney  stone  and  tuberculosis.  In  doubtful  cases 
an  early  exploratory  incision  is  urgently  demanded. 

Prognosis. — The  prognosis  of  malignant  tumors  of  the  kidney  is  bad,  because 
they  are  not  diagnosed  early  enough.  Although  they  are  comparatively  slow  in 
growth  and  may  extend  over  a  period  of  years  (ten  or  fifteen),  the  ultimate  result 
is  usually  fatal.  Death,  as  a  rule,  occurs  from  extension's  and  metastases;  some- 
times from  renal  insufficiency  and  hematuria. 

Treatment. — Most  cases  are  diagnosed  too  late  for  radical  treatment.  AVhen 
the  growth  is  discovered  early,  immediate  nephrectomy  is  indicated.     If  there  are 


SIO  SURGERY  OF  THE  KIDNEY. 

evidences  either  of  direct  extension  of  the  tumor  to  the  surrounding  structures  or  of 
metastases,  operation  is  hopeless. 

Extension  to  surrounding  structures  is  indicated  by  a  fixation  of  the  kidney. 
Extension  to  the  renal  vein  can  only  be  diagnosed  after  the  kidney  is  exposed  at 
operation.  The  presence  of  varicocele  in  the  case  of  a  tumor  of  the  left  kidney 
speaks  neither  for  nor  against  the  involvement  of  the  renal  vein.  Thrombotic 
tumor  masses  in  the  vena  cava  may  be  productive  of  no  s^nnptoms;  nevertheless, 
a  suspicion  of  this  condition  is  well-founded  if  a  thrombophlebitis  of  the  femoral 
vein,  or  a  dilatation  and  engorgement  of  the  veins  of  the  abdominal  wall,  scrotum, 
and  lower  extremities,  make  their  appearance. 

The  bones  especially  deserve  attention  when  evidences  of  metastases  are  sought. 
Not  only  enlargements,  but  areas  of  tenderness  and  a  feeling  of  weakness  in  them, 
may  be  indicative  of  a  secondary  growth. 

It  is  of  less  importance  to  determine  the  condition  of  the  opposite  kidney  than 
in  the  case  of  nephrectomy  for  other  lesions,  because  nephrectomy  is  the  only  hope 
for  a  malignant  tumor  and  a  bilateral  affection  is  unlikely.  Nevertheless,  as  a 
matter  of  prognosis,  the  excretory  functions  of  the  two  kidneys  should  be  estimated 
as  accurately  as  possible. 

In  the  forty-three  cases  of  Israel  there  were  eight  operative  deaths,  five  of  them 
directly  traceable  to  cardiac  degeneration.  The  author  calls  attention  particularly 
to  this  danger  in  nephrectomy  for  malignant  tumor.  Of  twenty-nine  cases  which 
were  operated  on  more  than  three  years  before  his  report,  there  were  seven  which 
died  either  at  the  time  of  operation  or  from  some  intercurrent  disease.  Of  the  re- 
maining twenty-two,  fourteen  had  recurrences  and  eight  have  remained  healthy  for 
fourteen,  twelve,  ten,  eight,  six,  five,  five,  and  three  years  respectively. 

As  in  all  other  forms  of  malignant  tumor,  the  keynote  to  successful  surgical 
treatment  is  early  diagnosis  and  early  operation.  (See  treatment  of  embryonal  or 
mixed  tumors,  p.  806,  and  nephrectomy,  p.  836.) 


TUMORS  OF  THE  RENAL  PELVIS. 

Malignant  Papilloma. — The  most  common  tumor  of  the  renal  pelvis  is 
malignant  papilloma  (Fig.  849).  Israel  saw  two  in  his  series  of  sixty-eight  malig- 
nant tumors  of  the  kidney.  As  Kelly^  has  noted,  there  is  usually  a  multiplicity  of 
lesions  in  malignant  papilloma  of  the  renal  pelvis.  Thus,  among  the  cases  collected 
by  him,  in  two  the  kidney  and  the  ureter,  in  one  the  kidney  and  the  bladder,  in  one 
the  kidney,  the  ureter,  and  the  bla'dder,  and  in  one  both  kidneys  and  the  bladder, 
were  involved.  Renal  calculus  has  often  been  found  in  association  with  these 
tumors. 

The  s^miptoms,  prognosis,  and  treatment  are  the  same  as  in  the  other  malignant 
tumors  of  the  kidney. 

1  Kelly,  A.  O.  J.:  "Papillomatous  Epithelioma  of  the  Pelvis  of  the  Kidney,"  Proc.  Path. 
See.  Phila.,  1900,  N.  S.,  vol.  iii,  No.  9,  p.  217. 


TUMORS    OF   THE    RENAL    PELVIS. 


811 


Adrenal  Tumors. — Adrenal  tumors  are  exceedingly  malignant.  They  are 
rapid  in  growth  and  are  complicated  by  lymphatic  and  visceral  metastases  very 
early.  As  they  increase  in  size  they  push  the  kidney  downward.  Pain  from  pres- 
sure on  the  spinal  nerves  at  their  exit  from  the  intervertebral  spaces  may  be  an  early 
symptom.  The  proximity  of  the  growth  to  the  pleura  and  to  the  vena  cava  on  the 
right  side  explains  the  frequency  of  early  pleural  extensions  and  venous  stasis. 
The  pressure  of  the  tumor  may  produce  urinary  symptoms  like  those  of  a  kidney 
tumor,  and  a  diagnosis  before  exposure  between  an  adrenal  and  a  renal  tumor  is 
almost  impossible.  Unless  undertaken  very  early  and  the  tumor  is  without  exten- 
sions, extirpation  should  not  be  attempted. 

Pararenal  Tumors. — According  to  Kiister,  the  symptoms  and  the  course  of 
tumors  affecting  the  kidney  capsule 
and  its  environs  differ  from  those  of 
the  kidney  itself.  They  are  never 
associated  with  alterations  of  the 
urine.  The  only  important  symptom 
is  the  appearance  of  a  palpable  tumor 
in  the  abdomen.  This  is  felt  beneath 
the  border  of  the  ribs,  and  during  its 
growth  further  downward.  It  may 
be  smooth  or  knobby;  it  feels  hard, 
doughy,  or  in  the  case  of  soft  lipomata 
or  myxomata  there  may  be  indistinct 
fluctuation.  Its  position  corresponds 
to  that  of  a  kidney  tumor,  and  it  may 
be  fairly  mobile.  There  may  be  diges- 
tive disturbances,  constipation,  dys- 
pnea, emaciation,  cachexia,  and  edema 
of  the  legs.  A  pararenal  tumor  may 
l)e  distinguished  from  paranephritis  by 
the  absence  of  inflammatory  symptoms 
and  the  disassociation  with  renal  calcu- 
lus, pyonephrosis,  and  pyelonephritis. 

The  prognosis  of  these  tumors  is  bad.  Without  operation  they  are  almost 
invariably  fatal.  The  operative  removal  is  very  difficult.  Kiister  reports  that 
operation  was  undertaken  in  fifty-six  out  of  seventy  cases,  but  the  difficulty  of 
operation  was  so  great  that  eleven  of  the  fifty-six  operations  were  incomplete;  of 
these  eleven  cases,  ten  died  at  the  close  of  operation  or  lived  for  a  very  short  time. 
In  the  remaining  forty-five  cases,  seventeen  died  as  a  direct  result  of  the  operation. 

Cystic  Tumors  of  the  Kidney. — Simple  or  Reiention  Cysts. — Simple  cysts 
spring  from  the  outer  region  of  the  cortex  and  are  bordered  by  the  compressed 
parenchyma  of  the  kidney.  Contracted  kidney  is  often  associated  with  simple 
cysts.     They  may  be  multiple,  they  are  usually  solitary,  and  they  are  never  grouped. 


Fig.  849. — Papillary  Carcinoma  of  Kidney. 


812  SURGERY  OF  THE  KIDNEY. 

Two  contiguous  cysts  may  unite  by  the  destruction  of  an  intervening  septum. 
They  arise  either  from  the  capsule  of  Bowman  or  from  a  kidney  tubule.  Many 
never  attract  any  attention  and  scarcely  more  than  half  of  them  could  be  detected 
by  palpation,  if  deliberately  sought.  The  cyst  may,  however,  grow  to  an  enormous 
size.  The  symptoms  are  those  of  nephritis,  pressure,  and  tumor.  The  preferable 
treatment  is  partial  nephrectomy.  If  this  is  not  feasible,  incision  and  drainage  or 
total  nephrectomy  is  indicated. 

Polycystic  Disease  of  the  Kidney. — Polycystic  degeneration  of  the  kidney 
may  be  noticeable  at  birth  or  it  may  appear  later  in  life.  If  congenital,  it  is  often 
accompanied  by  other  deformities  of  the  urogenital  apparatus.  The  form  which 
appears  in  adults  usually  develops  from  an  adenocystoma  and  destroys  the  renal 
tissue. 

Kiister  compares  the  external  appearance  of  a  polycystic  kidney  to  a  bunch  of 
grapes  (Fig.  850).  The  vesicles  of  larger  and  smaller  size  are  often  found  closely  in 
relation  to  one  another.  In  other  cases  the  cysts  are  less  numerous  and  rests  of 
healthy  kidney  tissue  are  found  between  them.  In  some  cases  the  degeneration  is 
confined  to  a  certain  spot,  e.  g.,  one  pole  of  the  kidney.  The  size  of  the  individual 
cyst  varies  from  one  barely  visible  to  one  having  the  circumference  of  a  hazelnut.  In 
the  cortical  substance  the  cysts  are  usually  round ;  in  the  medulla  they  are  frequently 
elongated  or  sausage-shaped.  Alterations  may  be  found  in  the  ureter,  the  kidney 
pelvis,  and  the  kidney  calyces.  The  calyces  and  the  pelvis  are  sometimes  almost 
fully  replaced  by  connective  tissue.  The  upper  part  of  the  ureter  may  be  changed 
into  a  solid  string;  at  other  times  the  ureter  is  only  narrowed,  and  the  wall  is  con- 
centrically thickened. 

Symptoms. — Israel  divides  cases  of  polycystic  disease  into  four  groups,  depending 
on  the  symptoms  which  they  present.  In  the  first  group  there  are  no  indications 
of  renal  involvement  until  uremia  makes  its  appearance.  In  the  second,  there  are 
polyuria,  occasionally  hematuria,  dysuria,  great  thirst  and  dryness  of  the  mouth, 
and  slight  edema.  A  third  class  may  show  particularly  disturbances  of  the  cir- 
culatory apparatus,  such  as  palpitation,  dyspnea,  and  vertigo.  Other  cases  seek 
medical  advice  because  of  distention  of  the  abdomen  with  a  feeling  of  tension, 
anorexia,  vomiting,  and  digestive  disturbance. 

A  palpable  tumor  in  one  or  both  kidney  regions  has  been  observed  in  one-third 
of  the  entire  number  of  cases.  Under  favorable  conditions  it  is  possible  to  determine 
that  the  surface  of  the  organ  is  covered  with  small  knobs  varying  in  size  from  a 
pea  to  an  egg. 

Diagnosis. — It  may  be  difficult  to  distinguish  this  sort  of  a  kidney  tumor  from 
hydronephrosis  and  new-growths.  Hematuria  is  neither  so  frequent  nor  so  severe 
as  in  malignant  tumors  of  the  kidney.  A  surface  covered  with  small  knobs  of 
considerable  hardness  is  a  good  indication  of  cystic  kidney,  but  it  may  also  be  due 
to  multiple  new-growths,  stone,  tuberculosis,  or  a  lobulated  kidney  of  fetal  origin. 
When  the  diagnosis  is  doubtful,  an  exploratory  incision  is  indicated. 

Prognosis. — Although  some  cases  of  cystic  kidney  give  rise  to  no  great  trouble, 


TUMOES   OF  THE   RENAL 


being  found  at  autopsy  inpatients  eighty 


PELVIS. 


to  ninety  years  old,  most  Of  them 


813 


occasion 


Fi.^  SoO.-PoLYcYSTic  Disease 


OF  THE  Kidney. 

icklj  in  deati 
o-  .n  any  great  measure;  usually  the  outlo'ok  is'^baT 


symptoms  and  end  more  or  less  n,„VH    •    .,      , 

time  has  improved  the  proglosi!  ?  r"^.!"  '""*■     ^^  f°™  of  treatment 


up  to  this 


814  SURGERY    OF   THE    KIDNEY. 

Treatment. — The  treatment  should  be  medical  and  not  operative.  Nephrectomy 
is  dangerous  on  account  of  the  frequency  with  which  the  disease  is  bilateral.  Neph- 
rotomy effects  no  permanent  reduction  in  the  enlargement  of  the  kidney  and  does 
not  influence  the  course  of  the  disease.  It  is  better  to  treat  the  case  by  medical 
means  as  one  of  contracted  kidney. 

Adenocystoma. — Adenocystoma  of  the  kidney  may  be  benign  or  malignant. 
The  benign  form  resembles  and  may  be  the  early  stage  of  polycystic  kidney  disease, 
and  demands  the  same  treatment.  Malignant  adenocystoma  presents  all  of  the 
general  features  of  the  other  malignant  renal  growths.  Hematuria,  renal  colic, 
and  local  urinary  symptoms  are  more  pronounced  than  in  the  benign  form.  An 
exploratory  incision,  however,  may  be  required  before  a  differential  diagnosis  can 
be  made. 

Pararenal  Cysts. — Cysts  of  the  capsule  or  of  the  bordering  connective  tissue 
may  be:  blood  cysts  resulting  from  trauma;  epithelial  cysts  due  to  evagination 
of  the  kidney  pelvis;  lymph  cysts;  cysts  from  displaced  rests  of  the  Wolffian  body; 
dermoid  cysts,  A  great  number  of  the  reported  cases  have  been  found  at  autopsy; 
their  only  evidence  is  a  tumor,  which  careful  examination  will  show  has  a  connection 
with  the  kidney.  The  prognosis  is  very  good.  Kiister  reports  thirteen  cases 
treated  surgically;  only  one  ended  in  death,  and  this  was  in  a  man  of  seventy  years. 

Echinococcus  Cysts  of  the  Kidney. — White  and  Martin  state  that  the  kidney 
is  affected  in  5.8  per  cent,  of  all  cases  of  hydatid  disease.  The  condition  develops 
slowly  and  forms  a  smooth,  round,  movable  tumor  of  the  kidney.  The  tumor 
may  be  hard  or  semi-fluctuant.  The  urinary  constituents  are  not  much  affected 
unless  the  cyst  bursts  into  the  pelvis,  when  booklets  and  daughter  cysts  are 
found  in  the  urine.  Suppuration  may  occur  in  the  cyst  either  from  trauma  or  from 
infection  after  rupture  into  the  kidney  pelvis.  Usually  there  is  little  pain,  but  if 
the  cyst  bursts  into  the  pelvis  there  may  be  renal  colic.  The  treatment  is  incision 
and  suture  of  the  sac  wall  to  the  lumbar  wound  after  removing  the  contents  of  the 
sac.  This  applies  to  clean  as  well  as  to  suppurating  cases.  Resection  may  be 
done  in  aseptic  cases  if  the  situation  of  the  cyst  is  favorable. 


RENAL  NEURALGIA. 
Pain  in  the  region  of  the  kidney  is  not  always  due  to  a  renal  affection.  Thus 
the  pain  of  intercostal  and  muscular  neuralgia,  irritation  of  the  posterior  spinal 
nerve-roots  from  any  cause,  lumbago,  spinal  caries,  abdominal  aneurism,  pleuro- 
pneumonia, and  duodenal  ulcer  may  be  referred  to  the  loin.  A  form  of  pain 
closely  simulating  renal  colic  is  said  to  be  due  to  malarial  poisoning.  Neuralgic 
reflex  pain  is  sometimes  observed  in  the  right  lumbar  region  in  cases  of  hypertrophy 
of  the  left  ventricle,  the  result  of  aortic  regurgitation.  Pain  in  the  loin  has  also 
been  due  to  engorgement  and  enlargement  of  the  kidney  at  the  menstrual  period, 
and  acid  urine  may  produce  not  only  lumbar  pain  but  also  frequent  micturition 
and  even  a  slight  amount  of  pus  or  blood  in  the  urinary  excretion.     The  differential 


RENAL    HEMORRHAGE    OF    UNEXPLAINED    ORIGIN. 


815 


diagnosis  between  these  conditions  and  actual  renal  disease  is  usually  made   bj 
observing  the  course  of  the  affection  and  the  result  of  certain  plans  of  treatment. 

In  some  cases  no  renal  dis- 
ease can  be  discovered,  and  yet 
the  physician  is  finally  forced 
to  the  conclusion  that  the  pain 
is  actually  renal  in  origin.  In 
this  event  exploratory  nephro- 
tomy is  justifiable  as  a  last  re- 
sort, and  even  though  no  lesion 
of  the  kidney  is  found,  the  re- 
lief of  tension  which  follows 
section  of  the  kidney  capsule 
has  often  cured  the  patient. 
It  is  probable  that  in  some 
cases  where  no  gross  lesion  is 
found  at  operation  a  micro- 
scopic examination  of  the  tis- 
sue of  the  kidney  would  show 
some  form  of  Bright's  disease. 


RENAL  HEMORRHAGE   OF 
UNEXPLAINED  ORIGIN. 

Cases  have  been  reported 
from  time  to  time  of  renal 
hemorrhage  in  which  no  pa- 
thologic condition  of  the  kid- 
ney could  be  found.  Klemp- 
erer  believes  that  such  cases 
are  examples  of  a  disturbance 
in  the  vasomotor  fibers  of  the 
kidney  causing  a  dilatation  of 
the  blood-vessels  and  a  conse- 
quent diapedesis  of  the  red 
blood -corpuscles. 

Schenck'^  reported  a  case 
of  this  sort  in  which  every 
means  was  exhausted  to  find 
out  what  produced  the  hema- 
turia.    Examination  was  absolutely  negative,  and  the  bleeding  disappeared  four 


Fig.  851. — Unilateeal  Cystic  Kidney  (Cullen's  Case);   J  natural 


*  Schenck,  Benjamin  R.:     "Renal  Hematuria  of  Unexplained  Origin;  Report  of  a  Case  with 
Cessation  after  Nephrotomy,"  Med.  News,  1904,  vol.  Ixxxv,  p.  1206. 


816 


SURGERY   OF   THE   KIDNEY. 


weeks  after  the  operation  and  had  not  reappeared  at  the  time  the  report  was  made, 
two  years  later.  Schenck  beUeves  that  many  cases  of  so-called  idiopathic  renal 
hemorrhage  have  not  been  sufficiently  examined.  Before  such  a  diagnosis  can  be 
rio-htly  made,  the  kidney  must  be  split  from  end  to  end  and  a  portion  of  the  cortex 
subjected  to  a  microscopic  examination.  He  thinks  that  it  would  be  far  more 
scientific  to  put  such  cases  aside  as  unexplained  than  to  admit  them  under  the 
classification  of  idiopathic  hematuria. 


SURGICAL  TREATMENT  OF  DISEASES  OF  THE  KIDNEY. 

The  operations  performed  for  diseases  of  the  kidney  comprise: 

1.  Incision  into  the  paranephric  area. 

2.  Nephropexy. 

3.  Decortication  of  the  kidney. 

4.  Nephrotomy. 

5.  Nephrotresis. 

6.  Nephrolithotomy. 

7.  Nephrectomy,  total  and  partial. 

8.  Nephro-ureterectomy. 


Fig.  852. — Edebohls'  Positiox. 


The  conditions  which  indicate  the  performance  of  these  operations  include  the 
entire  field  of  surgical  diseases  of  the  kidney,  and  one  of  the  operations — namely, 
decortication — has  been  recently  used  for  certain  forms  of  chronic  disease  of  the 
kidney  formerly  relegated  to  the  domain  of  medicine  alone. 

General  Remarks  on  Kidney  Operations. — The  indications  for  operation 
haye  already  been  given  in  the  paragraphs  devoted  to  the  various  kidney  lesions. 
The  preparatory  treatment  of  the  patient  is  very  much  like  that  for  a  laparotomy. 
The  urinary  excretion  deserves  particular  attention,  and  any  abnormalities  should 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE   KIDNEY. 


817 


be  corrected  as  far  as  possible.  The  preparation  of  the  intestinal  tract  and  the  local 
disinfection  of  the  skin  overlying  the  operative  area  is  the  same  as  for  any  major 
operation. 

Position  of  the  Patient. — As  a  rule,  the  prone  position  is  the  most  convenient, 
the  abdomen  being  supported  by  a  firm  pillow  or  an  Edebohls  cushion,  which  flexes 
the  spine  and  increases  the  distance  between  the  lower  border  of  the  ribs  and  the 
crest  of  the  ilium  (Fig.  852).  For  lumbar  nephrectomy  or  nephro-ureterectomy  the 
patient  should  occupy  a  lateral  position  with  a  cushion  beneath  the  loin  of  the  oppo- 
site side.  In  a  transperitoneal  operation  on  the  kidney  the  ordinary  dorsal  position 
is  used. 

Post-operative  Treatment. — There  is  little  in  the  post-operative  treatment  that 
is  peculiar  to  kidney  cases,  the  usual  care  of  a  laparotomy  being  suitable  here. 
Although  post-operative  intestinal  distention  is  not  uncommon,  probably  from 
trauma  to  the  adjacent  large  gut,  there  is  less  danger 
of  peritonitis.  The  functional  activity  of  the  kidneys 
may  be  a  source  of  anxiety,  especially  after  nephrec- 
tomy and  after  nephrotomy  for  stone,  and  for  this 
reason  large  quantities  of  water  should  be  exhibited 
by  the  mouth  and  rectum.  Following  nephropexy 
it  is  advisable  to  keep  the  patient  in  bed  for  three 
weeks.  After  the  other  operations  the  patient  may 
be  allowed  out  of  bed,  if  the  general  condition  per- 
mits, at  the  end  of  ten  days.  The  bowels  should  be 
moved  after  the  second  day,  by  using  the  measures 
already  described  for  laparotomies. 

Incision  for  Exposing  the  Kidney. — There  are  a 
number  of  incisions  for  exposing  the  kidney,  some  of 
them  especially  suited  to  certain  operations. 

Edebohls'  incision  (Fig.  853)  is  suitable  for  neph- 
ropexy, for  decapsulation  of  the  kidney,  and  for  nephrotomy.^  With  the  patient  in 
the  prone  position,  the  cushion  underlying  and  supporting  the  abdomen,  an  inci- 
sion is  carried  from  the  twelfth  rib  to  the  crest  of  the  ilium,  along  the  outer 
margin  of  the  erector  spinse,  without  opening  the  sheath  of  that  muscle.  The 
fibers  of  the  quadratus  lumborum  muscle  are  bluntly  separated  in  their  course 
without  cutting,  or  preferably  the  muscle  is  displaced  inward.  The  iliohypogastric 
nerve  is  sought  for  in  front  of  and  along  the  outer  margin  of  the  quadratus,  and 
turned  to  one  side  out  of  the  way  of  danger;  the  transversalis  fascia  is  divided, 
exposing  the  perirenal  fat,  which  is  caught  with  artery  forceps  and  divided  well  to 
the  inner  and  posterior  part  of  the  wound  in  order  to  avoid  the  colon.  The  separa- 
tion of  the  perirenal  fat  is  completed  by  means  of  the  finger  until  the  kidney  is 
felt  in  the  depths  of  the  wound  and  seen. 


Fig.  853. — Edebohls'  Incision. 


'  Edebohls,  George  M.: 
1901,  Ix,  961. 

VOL.  II — 52 


"The  Cure  of  Chronic  Bright's  Disease  by  Operation,"  Med.  Record, 


818 


SURGERY    OF   THE   KIDNEY. 


Fig. 


854. — Robson's 

SION. 


Inci- 


Robson's  incision  is  suitable  for  nephrotomy  and  for  nephrectomy.  It  has  the 
advantage  of  exposing  the  kidney  by  spHtting  the  muscles  in  their  course,  without 
dividing  muscle  fibers  or  weakening  the  abdominal  wall,  and  without  wounding 

vessels  or  nerves.  Robson's^  operative  incision  (Fig.  854) 
is  begun  to  the  inner  side  of  the  anterior  superior  spine  of 
the  ilium,  and  is  carried  backward  obliquely  toward  the 
tip  of  the  last  rib.  The  fibers  of  the  external  oblique  and 
its  aponeurosis  are  separated  and  retracted,  exposing  the 
internal  oblique  muscle,  the  muscular  fibers  of  which  are 
split  on  a  line  between  the  ninth  costal  cartilage  and  the 
posterior  superior  spine  of  the  ilium,  in  which  position  they 
are  longer  than  in  front  or  behind  that  line.  The  fibers 
of  the  transversus  are  split  and  retracted  along  with  the 
oblique  muscle. 

A  diamond-shaped  space  is  thus  formed,  at  the  bottom 
of  which  is  seen  the  transverse  fascia;  this  is  incised,  ex- 
posing the  perirenal  fat,  and  on  pushing  through  the  fat  the 
kidney  is  easily  reached  in  whatever  position  it  may  lie. 
This  incision  gives  plenty  of  room,  and  if  needful  the 
whole  hand  can  be  introduced  into  the  circumrenal  space. 
If  it  becomes  necessary  to  expose  the  ureter,  the  incision  may  be  continued  obliquely 
downward  toward  Poupart's  ligament.  The  internal  oblique  will  then  require 
suture  to  bring  together  the  divided  ends.  Preferably  a  second  lower  incision 
through  the  outer  border  of  the  rectus  muscle  may  be 
made  to  reach  the  ureter. 

Kelly's  Incision. — Kelly  finds  the  superior  lumbar 
triangle  the  most  satisfactory  avenue  for  the  exposure 
of  the  kidney  except  in  malignant  cases  (Fig.  855). 
The  boundaries  of  the  triangle  are  the  posterior  mar- 
gins of  the  oblique  muscles  of  the  abdominal  wall,  the 
quadratus  lumborum,  and  the  twelfth  rib.  Its  floor 
is  formed  by  the  aponeurosis  of  the  oblique  muscles 
and  the  latissimus  dorsi  covers  it.  The  oblique 
incision  which  Kelly  uses  is  about  three  inches  long, 
extending  downward  and  outward  from  the  little  soft 
yielding  spot  in  the  angle  between  the  quadratus 
lumborum  and  the  rib,  exposing  the  latissimus,  which 
can  be  lifted  up  like  a  lid  or  separated  in  the  direc- 
tion of  its  fibers  or  simply  divided  transversely.     The 

whitish  area  of  the  apex  of  the  triangle  is  thus  exposed.     A  pair  of  closed  forceps 
is  then  pushed  through  the  aponeurosis  and  withdrawn,  when  the  golden-yellow 

iRobson,  A.  W.  Mayo:  "A  Method  of  Exposing  and  Operating  on  the  Kidney  without 
Division  of  Muscles,  Vessels  or  Nerves,"  Lancet,  1898,  May  14,  p.  1315. 


Fig.  855. — Kelly's  Incision. 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE   KIDNEY. 


819 


Fig      856. — Morkis'     Incision 
FOR  Nephrolithotomy. 


fat  pops  out.     The  opening  is  enlarged  by  blunt  force,  giving  command  of  the  entire 

field  without  the  ligation  of  a  single  vessel.     Enlargement  of  the  incision  is  easily 

effected  by  further  separating  the  oblique  muscle  fibers,  or  by  dividing  them  in  a 

direction  downward  and  outward.     Care  must  be  taken 

not  to  injure  either  the  last  dorsal  or  the  first  lumbar 

nerve. 

Morris'  Incision   for  Nephrolithotomy. — Morris   ex- 
poses the  kidney  by  an  incision  (Fig.  856)  starting  about 

three-fourths  of  an  inch  below  the  last  rib,  at  the  outer 

border  of  the  erector  spinse,  running  parallel  to  the  rib 

or  in  a  slightly  more  downward  direction  for  about  four 

and  a  half  inches.      "The  structures  divided  are  the 

skin,  the  superficial  fascia  and  the  fat,  the  outer  border 

of  the  latissimus  dorsi,  and  the  posterior  border  of  the 

external  oblique;   the  internal  oblique  and  the  lumbar 

fascia  are  exposed  and  divided  to  the  full  extent  of  the 

wound.     The  last  dorsal  nerve  and  the  subcostal  artery 

with  its  vein  run  along  the  lower  border  of  the  last  rib 

and  usually  escape  being  divided,  but  not  infrequently 

they  pierce  the  lumbar  fascia  and  take  a  lower  course, 

when  they  may  cross  the  line  of  incision.     If  so,  they  are  best  divided,  the  artery 

being  ligatured  and  an  inch  or  more  of  the  nerve  excised.     If  the  last  dorsal  nerve 

after  keeping  along  the  lower  edge  of  the  last  rib  pierces  the  muscular  fibers  of 

the  transversalis  instead  of  the  fascia  lumborum,  it 
will  escape;  but  the  lateral  cutaneous  branch  of  the 
last  dorsal  nerve,  which  pierces  the  external  and  in- 
ternal oblique  muscles  and  takes  an  oblique  course  to 
the  crest  of  the  ilium,  is  necessarily  divided.  The 
trunk  of  the  iliohypogastric  nerve  is  usually  below 
the  line  of  incision  and  is  not  seen.  Its  hypogastric 
branch  lies  parallel  to  the  incision,  in  front  of  the  iliac 
spine  and  below  it,  and  is  not  divided  unless  the  inci- 
sion is  carried  as  far  inward  as  the  external  abdom- 
inal ring,  where  the  nerve  may  be  cut  near  its  term- 
ination. 

The  lumbar  fascia,  and  at  the  front  of  the  wound 
some  of  the  fibers  of  the  transversalis  fascia,  are  divided 
to  the  full  extent  of  the  incision.  This  should  be  done 
very  carefully,  because  in  thin  subjects  the  peritoneum 
is  close  beneath  the  transverse  muscle  and  very  ad- 
herent to  the  intervening  fascia.     The  outer  edge  of 

the  quadra tus  lumborum  is  exposed,  and  if  the  muscle  is  broad,  it  should  be  divided 

as  far  back  as  the  limit  of  the  skin  incision.     The  transversalis  fascia  should  be 


Fig.  857. — Morris'  Incision  for 
Nephrectomy  .vnd  Line  of 
Secondary  Incision. 


820 


SURGERY    OF   THE   KIDNEY. 


divided,  and  when  this  is  done,  a  smooth  and  glistening  celkilo-fibrous  sheath  of 
paranephric  fascia  containing  the  fatty  capsule  of  the  kidney  will  bulge  into  the 
wound  at  the  back,  and  the  subperitoneal  fat  will  be  seen  further  forward."  As 
the  perinephric  fascia  may  easily  be  mistaken  for  the  peritoneum,  it  should  be  a 
rule  to  cut  into  the  fascia  at  the  posterior  extremity  of  the  wound  near  the  erector 
spin  86. 

Morris'  Incision  for  Nephrectomy  (Fig.  857)  is  the  same  as  the  one  used  for 
nephrotomy,  but  in  order  to  gain  more  room,  he  sometimes  joins  to  the  first  incision, 
about  an  inch  in  front  of  its  posterior  extremity,  another  one  running  vertically 
downward  or  upward.     This  secondary  incision  may  be  left  until  the  kidney  has 

been  reached  and  explored,  and  it  can  then 
be  made  by  cutting  from  within  outward 
with  a  probe-pointed  bistoury  steadied  by 
the  index-finger  of  the  left  hand.  The 
vertical  incision  greatly  facilitates  the 
passing  of  the  ligature  around  the  pedicle. 
An  upper  cut  markedly  increases  the  room 
by  dividing  the  fibers  of  the  ligament  of 
Henle,  the  lower  end  of  which  hampers 
the  fingers  during  the  enucleation  of  the 
organ.  In  certain  cases  more  or  less  ad- 
vantage is  gained  by  excising  a  large  part 
of  the  twelfth  rib. 

Langenbuch's  Incision;  Transperi- 
toneal Incision. — Langenbuch^  practised 
removal  of  the  kidney  through  the  incision 
used  in  less  modern  times  for  celiotomy. 
The  incision  runs  along  the  outer  border 
of  the  rectus  muscle  of  the  affected  side. 
Its  mid-point  should  correspond  to  the 

Fig.    858.— Langenbuch's    Incision    and   Israel's        center    of    the    kidney    maSS.        It    is    USed 
Secondary   Incision   for   Nephrectomy    and 

Lithotomy.  f or  transperitoneal  or  abdominal  exposure 

of  the  kidney. 

Israel's  Incision. — Israel^  exposes  the  kidney  by  an  oblique  incision,  beginning 
at  the  junction  of  the  erector  spinse  with  the  twelfth  rib,  running  forward  and 
downward  to  a  point  two  or  three  fingerbreadths  to  the  median  side  of  the  anterior 
superior  spine  of  the  ileum  (Fig.  859).  This  direction  has  the  advantage  of  exposing 
the  upper  segment  of  the  ureter.  If  it  is  desirable  to  expose  this  further  downward 
toward  the  bladder,  the  incision  is  lengthened  from  its  lower  end  downward  and 
forward  parallel  to  Poupart's  ligament.     To  palpate  the  ureter  as  far  as  its  insertion 

'  Langenbuch:  Discussion  of  Barwell's  paper  on  Nephrectomy,  Trans.  Internat.  Med. 
Congress,  1881,  p.  278;  "Demonstration  eines  ^Yegen  rechtsseitigen  Nierencarcinoms  gliicklich 
laparotomirten  Knaben,"  Deutsch.  med.  Wochenschr.,  1885,  xi,  Nr.  48,  S.  838. 

^Israel,  James:     " Chirurgische  Klinik  der  Nierenkrankheiten,"  Berlin,  1901. 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE   KIDNEY. 


821 


into  the  bladder,  the  incision  may  be  lengthened  to  the  outer  border  of  the  rectus, 
or  to  operate  on  the  vesical  section  under  good  exposure  the  rectus  may  be  incised. 
If  this  incision  does  not  give  sufficient  room  in  difficult  nephrectomies,  Israel  uses 
a  second  incision  (Fig.  858) — a  transverse,  beginning  two  fingerbreadths  below 
the  border  of  the  ribs,  and  running  anteriorly  toward  the  rectus  muscle  at  right 
angles.  Israel's  incision  is  especially  applicable  to  nephrolithotomy  and  neph- 
rectomy. 

Special  Observations  Relative  to  Kidney  Operations. — Before  operat- 
ing on  any  case  in  which  nephrectomy  might  come  up  for  consideration,  it  is 
desirable  to  ascertain  the  functionating  power  of  each  kidney.  In  every  case  it  is 
essential  to  know  whether  the  urinary  excretion  is  abnormal  either  in  quality  or 
quantity,  and  if  it  is  abnormal  to  determine  whether  one  or  both  kidneys  are  affected. 
The  total  functionating  capacity  of  the  two  kidneys  is  revealed  by  cryoscopic  ex- 
amination of  the  urine  and  the  blood  and  by  the  estimation 
of  the  excretion  of  urea.  The  functional  condition  of  each 
particular  organ  can  be  demonstrated  with  the  help  of 
ureteral  catheterization. 

Ureteral  Catheterization. — The  technic  of  ureteral  cathe- 
terization in  women  is  given  in  Chapter  VIII,  vol.  I,  p. 
449.  For  the  technic  of  the  catheterization  of  the  ureters 
in  men  the  reader  is  referred  to  standard  treatises  on 
genito-urinary  diseases. 

Indigo-carmine  Test. — The  indigo-carmine  method  is 
useful  in  the  catheterization  of  the  ureters.  For  the  be- 
ginner it  serves  to  locate  the  ureteral  orifices  by  the  blue 
stream  of  urine,  and  it  aids  the  more  skilful  examiner 
when  the  openings  are  indistinct.  For  an  adult  the  dose 
is  80  mg. ;  20  cm.  of  a  0.4  per  cent,  solution  of  indigo-car- 
mine in  0.6  per  cent,  salt  solution  should  be  injected  into 
the  gluteal  muscles.     The  blue  color  appears  in  the  urine 

after  five  to  ten  minutes.  The  ingestion  of  much  fluid  will  dilute  the  urine  and 
make  the  test  less  satisfactory.  Consequently  for  several  hours  previous  to  the 
injection  only  a  slight  amount  of  fluids  should  be  taken.^ 

Determination  of  the  Renal  Function. — In  order  to  estimate  the  functional 
activity  of  the  kidneys,  there  are  several  tests  which  may  be  employed. 

Determination  of  the  Amount  of  Urea. — A  functional  incapacity  of  the  kidney 
may  be  assumed  if  the  quantity  of  urea  in  the  urine  persistently  falls  below  normal. 
The  usual  excretion  varies  between  20  and  25  grams  a  day.  If  the  urea  excreted 
in  the  twenty-four  hours  is  less  than  15  grams,  it  may  be  assumed  that  an  insuffi- 
ciency of  the  kidney  exists  to  such  an  extent  that  nephrectomy  is  inadvisable.  A 
single  determination  of  the  amount  of  urea  is  not  conclusive;    but  if  the  figures 


Fig.  859. — Israel's  Incision. 


^  Voelcker,  Fritz:     "Diagnose  der  chirurgischen  Nierenerkrankungen  unter  Verwertung  der 
Chromocystoskopie,"  1906,  Wiesbaden. 


822  SURGERY    OF   THE    KIDNEY. 

obtained  in  a  series  of  consecutive  days,  the  patient  taking  the  proper  amount  of 
nourishment,  are  approximately  identical,  the  results  are  trustworthy. 

Phloridzin  Test. — This  method  depends  upon  the  fact  that  after  a  subcutaneous 
injection  of  from  1  to  1.5  mg.  of  phloridzin  there  is  an  excretion  of  sugar,  if  the 
kidneys  are  healthy,  in  from  fifteen  to  twenty  minutes;  a  sugar  reaction  is  shown 
much  later  or  not  at  all  if  the  kidneys  are  diseased.  Ureteral  catheters  may  be 
placed  in  each  kidney,  so  that  the  sugar  reaction  can  be  taken  from  each  independ- 
ently. 

Cryoscopy. — Cryoscopy  is  the  determination  of  the  freezing-point  of  the  urine 
and  of  the  blood.  According  to  Kiimmelbit  is  the  best  method  of  ascertaining  the 
functional  activity  of  the  kidneys.  The  idea  on  which  the  method  is  based  is  that 
the  physiologic  activity  of  the  kidney  must  be  considered  as  a  form  of  osmosis,  and 
that  the  work  of  the  kidney  may  be  calculated  from  its  product,  the  urine,  and  the 
source  of  its  product,  the  blood-serum.  The  osmotic  concentration  of  the  blood  or 
the  urine  is  calculated  from  the  freezing-point.  The  more  concentrated  a  solution, 
the  further  the  freezing-point  is  below  that  of  distilled  water.  To  correctly  estimate 
the  freezing-point  of  the  blood,  a  skilled  examiner  is  absolutely  necessary,  and  a 
failure  to  insist  upon  this  point  will  lead  to  untrustworthy  reports.  The  details 
of  the  technic  used  by  Kiimmell  are  fully  described  in  his  paper  (/.  c),  to  which  the 
reader  is  referred. 

He  has  drawn  the  following  conclusions,  based  upon  seven  hundred  cases: 
When  the  kidneys  are  healthy,  the  molecular  concentration  of  the  blood  is  constant, 
and,  on  the  average,  corresponds  to  a  freezing-point  of  .56°  C  In  weakened  and 
anemic  individuals  an  increase  to  .55°  C.  and  even  to  .53°  C.  and  .52°  C.  is  sometimes 
observed.  Unilateral  disease  causes  no  change  in  the  freezing-point  of  the  blood.  The 
normal  freezing-point  (.56°  C.)  proves  only  that  so  much  functionating  kidney  tissue 
is  present  as  is  necessary  to  excrete  sufficiently  the  products  of  tissue  metabolism. 
Because  in  a  given  case  one  kidney  may  be  doing  the  work  of  two,  and  because  the 
normal  freezing-point  of  the  blood  does  not  indicate  two  healthy  kidneys,  ureteral 
catheterization  should  be  performed  and  positive  determination  of  urinary  excretion 
from  each  kidney  should  be  made.  A  normal  amount  of  urea  and  a  normal  freezing- 
point  of  the  urine  are  invariably  associated  witli  a  normal  freezing-point  of  the  blood. 
A  lowering  of  the  freezing-point  of  the  blood  indicates  that  the  kidneys  are  not 
entirely  equal  to  the  required  work.  If  the  freezing-point  of  the  blood  falls  to 
.6°  C,  according  to  Kiimmell's  experience,  nephrectomy  should  not  be  undertaken 
and  nephrotomy  only  when  it  is  absolutely  necessary. 

Nephrectomy  may  be  performed^  secondarily  if  the  freezing-point  has  improved 
and  reached  the  normal.  Otherwise  nephrectomy  should  not  be  considered.  In 
five  cases  in  which  nephrectomy  was  performed  notwithstanding  a  lowering  of  the 
freezing-point  below  .6°  C,  death  from  uremia  occurred  after  a  short  time.  In  about 
three  hundred  cases  in  which  the  freezing-point  was  lowered  below  .6°  C,  the  further 
course  of  the  disease  and  the  post-mortem  examination  or  nephrotomy  proved  the 
correctness  of  Kiimmell's  beliefs. 


SURGICAL   TREATMENT    OF    DISEASES    OF   THE    KIDNEY.  823 

Without  ureteral  catheterization  the  condition  or  even  the  presence  of  the  second 
kidney  must  often  remain  in  more  or  less  doubt.  iVn  example  of  this  is  recorded 
by  Keen  and  Stewart/  a  case  of  calculous  pyelitis  in  which  nephrotomy  was  per- 
formed instead  of  nephrectomy,  examination  of  the  urine  showing  a  diminution  in 
the  excretion  of  urea.  Because  of  the  low  excretion  of  urea,  an  apparently  almost 
destroyed  and  useless  kidney  was  left  in  situ.  Following  operation  the  amount  of 
urine  from  both  kidneys  was  carefully  estimated,  and  it  was  found  that  the  kidney 
operated  on  secreted  about  four  and  a  half  times  as  much  urine  as  the  other  kidney. 
In  this  case  ureteral  catheterization  could  certainly  have  shown  the  condition 
previous  to  the  operation. 

When  for  one  reason  or  another  the  condition  of  the  second  kidney  is  doubtful, 
the  plan  of  Edebohls^  may  be  adopted.  This  author  says  that  before  extirpating 
any  kidney,  a  knowledge  of  the  presence  and  condition  of  the  other  kidney  is  of 
paramount  importance,  and  that  none  of  the  usual  aids  are  as  valuable  as  an  ex- 
ploratory incision.  "Delivery  and  examination  of  both  kidneys,  by  lumbar  ex- 
ploratory incision,  should  be  the  rule  in  every  contemplated  nephrectomy  in 
which  one  is  not  absolutely  and  beyond  peradventure  certain  of  the  condition  of 
the  other  kidney.  Modern  surgery  has  rendered  lumbar  exploratory  incision  a  safe 
and  expeditious  procedure,  the  most  and  generally  the  only  reliable  way  of  determin- 
ing the  exact  condition  of  the  other  kidney." 

Incision  into  the  Paranephric  Area. — For  the  exposure  of  the  paranephric 
tissues  and  for  the  opening  of  a  paranephric  abscess,  either  the  incision  of  Morris 
or  of  Kelly,  or  the  primary  incision  of  Israel,  may  be  used.  If  fluctuation  or  tumor 
is  present,  incision  should  be  made  over  the  most  prominent  point.  In  advanced 
cases  of  paranephric  abscess  the  pus  may  be  reached  almost  immediately  beneath 
the  skin;  in  others,  the  incision  will  have  to  be  carried  deeper  and  very  often  the 
tissues  will  be  hard  and  indurated.  After  exposing  the  paranephric  fat,  unless  pus 
is  encountered  at  once  the  finger  should  be  passed  in  different  directions  to  locate 
the  abscess. 

If  no  pus  is  found,  the  incision  should  be  carried  as  far  as  the  fibrous  capsule  of 
the  kidney,  and  especial  attention  should  be  given  to  the  areas  surrounding  the  upper 
pole  and  the  lower  posterior  border,  where  abscesses  are  most  likely  to  be  overlooked. 
When  the  abscess  is  opened,  the  pus  usually  discharges  readily.  In  some  cases  it 
comes  away  less  freely,  being  thick  and  caseous.  In  any  event  the  abscess  cavity 
should  be  thoroughly  washed  out  and  smaller  secondary  cavities  should  be  broken 
into  the  larger  one. 

It  is  nearly  always  desirable  to  determine  the  condition  of  the  kidney.     If, 

however,  the  organ  lies  entirely  separated  from  the  collection  of  pus,  and  if  its 

exposure  presents  much  difficulty,  simple  incision  and  drainage  of  the  paranephric 

pus  cavity  will  suffice  unless  exploration  is  demanded  by  the  kidney  symptoms. 

^  Keen,  W.  W.,  and  Stewart,  D.  D.:  "Nephrotomy  for  Calculous  Pyelitis,"  Therapeutic 
Gaz.,  Jan.  15,  1892,  viii,  p.  27. 

^  Edebohls,  George  M.:  "The  Other  Kidney  in  Contemplated  Nephrectomy,"  Ann.  Surg., 
April  18,  1898,  xxvii,  p.  425. 


824 


SURGERY    OF   THE    KIDNEY. 


When  the  kidney  lies  more  or  less  in  direct  relation  with  the  abscess,  it  should  be 
examined  carefully  to  see  whether  there  is  any  communication  between  it  and  the 
collection  of  pus.  Openings  in  the  kidney  calyces  and  pelvis  should  be  enlarged  by 
blunt  force  and  palpated  for  stone.  When  the  pus  has  burrowed  downward  along 
the  iliopsoas  muscles,  a  second  incision  should  be  made  near  the  anterior  superior 
spine  of  the  ilium,  approaching  the  abscess  behind  the  peritoneum  and  leaving  a 
drain  in  this  situation. 

Nephropexy. — All  nephropexy  operations  have  for  their  object  the  formation 
of  adhesions  which  will  fasten  the  kidney  to  the  muscles  of  the  loin.  There  are  two 
forms  of  operation.  In  the  first,  sutures  are  employed  and  the  kidney  is  directly 
fastened  to  the  lumbar  muscles;  in  the  second,  gauze  or  some  other  material 
is  placed  around  the  kidney  to  produce  adhesions  to  the  surrounding  parts. 

The  technic  of  fixation  by  suture  varies.  Hahn  suspended  the  kidney  the  first 
time  by  its  fatty  capsule,  but  this  was  soon  found  to  be  an  uncertain  method,  for 


Fig.  860. — Nephropexy  by  Edebohls'  Technic. 
The  capsule  of  the  kidney  has  been  reflected  and  the  suspension  sutures  have  been  introduced. 


the  capsule  was  often  so  weak  that  it  would  not  hold  the  kidney  in  place.  Sutures 
were  then  placed  directly  through  the  kidney  parenchyma.  The  objection  to  this 
method  is  that  the  sutures  do  harm  to  the  kidney  substance  and  occasionally  tear  out. 
Tuffier,  to  obviate  these  difficulties,  suggested  stripping  off  the  fibrous  capsule  of 
the  kidney  and  passing  the  fixation  sutures  either  through  this  structure  alone  or 
in  combination  with  the  kidney  parenchyma. 

By  Edebohls  and  others  the  fatty  capsule  is  entirely  excised,  on  the  ground  that 
its  interposition  in  any  way  between  the  kidney  and  the  lumbar  muscles  prevents 
union,  or  that  the  weight  of  the  capsule  tends  to  draw  the  kidney  downward.  Others 
preserve  the  fatty  capsule  and  place  it  below  the  kidney  to  act  as  a  pad  or  a  bolster 
for  the  organ  to  rest  upon. 

Few  use  the  fatty  capsule  at  present  as  a  means  of  support,  although  Harris 
fixes  the  kidney  by  narrowing  the  confines  of  the  perirenal  fascia. 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE   KIDNEY. 


825 


The  kidney  should  be  exposed  by  Edebohls'  or  Kelly's  incision.  It  is  advisable 
to  deliver  the  kidney  by  gently  tugging  on  the  fatty  capsule  at  one  or  other  pole 
of  the  organ,  aided  if  need  be  by  rolling  the  patient  upon  the  inflated  cushion. 
A  very  useful  procedure,  after  first  partially  separating  the  kidney  from  the  fatty 
capsule,  is  to  hook  the  index-finger  under  the  kidney  above  the  pelvis  and  vessels. 
By  means  of  gentle  traction,  as  a  rule,  the  kidney  is  easily  delivered.     If  for  any 


//  XII.  thorac.neri/e 


N^  Nsui  1  «\"  •,  f  T/ .  -  -T m.  intern,  obi. 

\     W-  \\--\-^-  extern,  obi 
""       '^  '         ^  ilioin^uin.n. 


Fig.  861. — Showing  the  Important  Anatomic  Relations  of  the  Loin  on  the  Right  Side  and  the  Incision 

MOST  Commonly  used  for  Nephropexy. 
The  relation  of  the  incisioQ  to  the  quadratus   lumborum,  the   latissimus  dorsi,  and    the   iliohypogastric  nerve 

should  be  especially  noted. 

reason  it  seems  extremely  difficult  to  deliver  the  kidney,  the  effort  should  be  aban- 
doned, even  though  this  may  necessitate  a  change  in  the  operative  technic  because 
of  the  danger  of  tearing  the  renal  vessels.  After  delivering  the  kidney,  Edebohls^ 
excises  the  entire  fatty  capsule.  Noble  separates  it  above  and  laterally  and 
makes  a  pad,  which  he  sutures  below  the  lower  pole  of  the  kidney.     Dunning  and 


'  Edebohls    George  M. 
2,  p.  137. 


"The  Technics  of  Nephropexy,"  Ann.  Surg.,  1902,  vol.  xxxv,  No. 


826 


SURGERY    OF   THE    KIDNEY. 


Keen^  use  the  fatty  capsule  as  a  means  of  suspension,  removing  a  certain  amount 
and  suturing  the  remainder  to  the  incision. 

If  the  capsule  proper  of  the  kidney  is  to  be  used  as  a  means  of  suspension,  it  is 
nicked  over  the  dorsum  of  the  kidney,  a  grooved  director  thrust  between  the  capsule 
and  the  kidney  substance,  and  the  former  divided  to  as  great  a  distance  as  desired. 
Edebohls  strips  it  equally  from  both  surfaces,  half-way  to  the  hilum,  and  sutures 

the  capsule  on  both  sides  to  the  borders  of 
the  incision  through  the  anterior  layer  of  the 
lumbar  fascia  which  covers  the  quadratus 
lumborum  muscle.  This  brings  the  raw 
surface  of  the  kidney  directly  in  apposition 
with  the  exposed  fibers  of  the  quadratus 
lumborum  muscle. 

Experience  has  shown  that  at  times 
severe  pain  in  the  kidney  is  cured  by  a 
nephrotomy  incision.  This  fact  should  be 
borne  in  mind  and  the  capsule  stripped  in 
those  cases  of  nephropexy  in  which  pain  has 
been  a  prominent  symptom  of  the  loose 
kidney. 

Halm  strips  the  jfibrous  capsule  of  the 
kidney  from  the  posterior  surface  only.  He 
then  sutures  the  borders  of  the  incised  fatty 
capsule  to  the  depths  of  the  incision,  while 
the  flap  of  fibrous  capsule  is  pulled  out 
through  the  incision  and  sutured  either  to 
the  skin  or  to  the  subcutaneous  tissue.  The 
wound  is  packed  with  gauze. 

There  is  some  question  whether  sutures 
in  the  kidney  parenchyma  are  harmful. 
Delhaes,  in  1882,  was  the  first  to  place  su- 
tures in  this  position.  According  to  Keen, 
the  passage  of  such  sutures  has  been  found 
to  do  no  harm  by  Bassini,  Vanneufville 
and  Tuffier.  On  the  other  hand,  Senn^  credits  Delageniere,  Zatti,  and  Al- 
barran  with  having  shown  that  sclerotic  connective  tissue  forms  in  the  vicinity  of 
these  sutures  with  a  corresponding  destruction  of  the  kidney  parenchyma. 

Edebohls,   Boldt,^  Montgomery,*   and  Villeneuve  have  reported   instances  of 


Fig.  862. — Old  Method  of  Passing  Sutures 
INTO  Kidney  Substance  in  Nephropexy. 
Observe  how  any  strain  upon  the  suture 
would  be  met  with  little  resistance,  the  connec- 
tive-tissue reticulum  and  the  blood-vessels  of  the 
kidney  cortex  running  parallel  with  the  suture. 


^  Keen,  W.  ^Y.:     "Nephrorrhaphy,"  Ann.  Surg.,  Aug.,  1S90,  vol.  xii.  p.  81. 

^  Serni,  Nicholas:  "Lumbar  Nephropexy  without  Suturing,"  Jour.  Amer.  Med.  Assoc, 
1897,  xxix,  p.  1190. 

^  Boldt,  H.  J.:  "A  Case  of  Nephrorrhaphy  Followed  by  Urinary  Fistula  and  Salpingo- 
oophorectomy,"  N.  Y.  Jour.  Gynec.  and  Obstet.,' 189.3,  vol.  iii.  No.  2,  p.  145. 

^Montgomery,  E.  E.:  Discussion:  Trans.  Phila.  Obstet.  Soc,  Amer.  Gynec.  and  Obstet. 
Jour.,  1900,  vol.  xvii.  No.  6,  p.  541. 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE   KIDNEY. 


827 


extravasation  of  urine  along  the  suture  tracts,  when  sutures  have  been  passed  directly 
through  the  kidney  substance.  While  this  is  a  very  rare  accident,  it  forms  the  basis 
of  a  legitimate  objection  to  the  method.  The  chief  disadvantage  in  direct  suture  of 
the  kidney  is  the  decided  risk  of  the  sutures  cutting  out,  as  the  organ  is  so  friable. 

Max  BrodeP  has  devised  a 
suture  which  inflicts  a  minimum 
amount  of  traumatism  and  at  the 
same  time  securely  fixes  the  kid- 
ney to  the  lumbar  muscles.  He 
describes  it  as  follows: 

1.  The  direction  of  the  suture 
is  not  parallel,  but  at  right  angles 
to  the  framework  of  the  cortex. 

2.  The  fibrous  capsule  being 
the  most  resistant  structure  is 
utilized  instead  of  the  kidney  sub- 
stance itself  to  furnish  the  main 
support  for  the  suture. 

3.  The  suture  is  passed  in 
the  form  of  a  triangle  through 
the  cortex  so  as  to  leave  two  su- 
ture bridges  on  the  surface  of  the 
kidney  (Tig.  863).  These  bridges 
bear  the  brunt  of  the  work,  and 
traction  on  the  suture  is  borne  by 
them  instead  of  by  the  circulatory 
or  the  secretory  structures  of  the 
kidney.  To  make  the  Brodel 
suture  tear,  the  bridge  must  pull 
the  fibrous  capsule  into  the  cor- 
tical substance  of  the  kidney,  a 
procedure  requiring  considerable 
force.  In  a  series  of  experiments 
simple  through-and-through  su- 
tures of  the  kidney  parenchyma 
tore  out  with  a  weight  of  800  to 
1000  gm.;  the  Brodel  suture  held 
without  tearing  either  capsule  or  cortex  at  3000  to  3200  gm.  It  is  superior  to  any 
yet  devised,  and  has  been  extensively  used  with  very  good  results. 

When  a  movable  kidney  is  sutured  to  the  lumbar  muscles  on  a  plane  with  the 
incision,  the  organ  is  below  its  normal  position.     Those  operators  who  attempt  to 

'  Brodel,  Max:     "A  More  Rational  Method  of  Passing  the  Suture  in  Fixation  of  the  Kidney," 
Amer.  Medicine,  1902,  vol.  iv,  No.  5,  p.  176. 


Fig.  863. — The  Brodel  Suture. 
Observe  that  the  pull  of  the  suture  is  at  right  angles  to  the 
connective-tissue  reticulum  and  the  blood-vessels  in  the  cortex, 
and  that  the  suture  is  further  supported  by  the  bridge  overljnng 
the  kidney  capsule. 


828 


SrRGERY    OF   THE    KIDXEY. 


a-rcfg' 


place  the  kidney  in  a  normal  position  pass  their  sutures  through  the  lower  half  of 
the  kidney  and  anchor  them  high  in  the  lumbar  incision,  so  that  the  upper  part  of 
the  kidney  rests  beneath  the  lower  ribs  (Fig.  864).  Indeed,  the  last  rib  has  been  re- 
sected in  an  effort  to  fix  the  kidney  in  its  original  site.  Those  who  are  content  to 
anchor  the  kidney  at  the  position  of  the  lumbar  incision  have  found  it  entirely  satis- 
factory. It  permits  fixation  of  both  poles  equally,  so  that  no  tilting  of  the  kidney 
occurs,  and  no  interference  with  its  vascular  supply  or  with  the  urinary  outflow  is 
possible,  as  pointed  out  by  Morris,   Edebohls,   Keen,   and   Dunning.     Dunning 

thinks  it  is  desirable  to  displace  the  kidney  down- 
ward to  the  lowest  limit  of  its  respiratory  range, 
in  order  to  relieve  it  from  undue  diaphragmatic 
pressure.  None  of  the  operators  quoted,  except 
Hahn,  who  fixes  the  kidney  by  means  of  sutures, 
employs  drainage. 

Senn  does  not  use  sutures.  He  excises  a  por- 
tion of  the  fatty  capsule  and  packs  gauze  between 
the  bared  capsula  propria  and  the  surrounding 
tissues,  for  the  purpose  of  exciting  adhesions. 
The  patient  is  kept  in  bed  four  or  five  weeks. 
Senn's  operation  or  the  principle  of  his  operation 
has  been  variously  modified.  The  best  is  that  of 
Penrose  and  Beyea,  who  pass  a  rubber  tube  around 
each  pole  of  the  kidney.  The  fatty  capsule  is  dis- 
posed of  so  that  traction  on  the  tubes  will  hold 
the  surface  of  the  kidney  against  the  lumbar 
muscles.  The  wound  is  closed  except  at  its  upper 
and  lower  extremities,  where  the  tubes  emerge. 
Traction  is  maintained  by  tying  the  tubes  over  a 
strip  of  gauze  covering  the  incision.  The  first 
dressing  is  made  on  the  tenth  day.  The  tubes  come 
away  without  difficulty  on  the  twenty-first  day,  and 
the  sinuses  resulting  close  in  three  to  four  days. 
By  this  procedure  two  fibrous  cords  are  produced 
uniting  the  kidney  firmly  to.  the  lumbar  muscles. 

The  subject  of  technic  has  been  rather  exten- 
sively presented  in  order  to  give  an  epitome  of 
the  best  ideas  that  have  been  advanced.  Noble's  technic  is  as  follow^s:  The  pa- 
tient lies  prone  upon  the  table.  The  Edebohls  air-cushion  is  placed  exactly 
beneath  the  epigastrium.  If  too  low,  it  will  tend  to  displace  the  kidneys  under 
the  ribs;  if  too  high,  it  does  no  good.  The  incision  is  made  along  the  external 
border  of  the  erector  spinse  muscle  from  the  twelfth  rib  toward  the  ilium.  It 
should  be  about  three  inches  in  length.  \ATien  the  muscles  are  reached,  they 
should  be  separated  as  far  as  possible  rather  than  cut,  in  order  to  preserve  the 


Fig.  864. — Showixg  the  Kidney  fixed  to 

THE    QUADRATUS   LuMBORrM    BY    THE 
BrODEL    SrTURE,    AND    THE    PuLL    OF 

THE  Suture  more  or  less  at  Right 
Angles  to  the  Kidney  Cortex. 
The  picture  represents  the  kidney  sus- 
pended in  its  normal  position,  the  upper 
pole  beneath  the  ribs  and  the  fixation  su- 
tures passed  through  one  surface  of  the 
lower  pole.  In  the  usual  nephropexy  the 
sutures  are  passed  through  both  poles  and 
the  organ  is  fixed  in  a  lower  position  than 
normal. 


SUKGICAL   TREATMENT    OF   DISEASES    OF   THE    KIDNEY. 


829 


integrity  of  the  posterior  wall  of  the  abdomen.  It  is  usually  necessary  to  ligate  cut 
vessels,  as  these  are  much  larger  than  in  the  anterior  wall.  Care  should  be  taken 
to  avoid  wounding  the  iliohypogastric  and  ilio-inguinal  nerves,  which  run  through 
the  field  of  operation  in  a  direction  about  parallel  with  the  border  of  the  quadratus 
lumborum  muscle.  If  one  of  these  be  cut,  it  sometimes  causes  annoying  paresthesia 
in  the  region  of  its  distribution.  "When  the  muscles  have  been  well  separated,  the 
subjacent  fascia  is  divided,  exposing  the  perirenal  fat.  This  is  drawn  outward  and 
downward  and  torn  through  as  near  the  spinal  column  and  as  high  in  the  wound  as 
convenient,  the  object  be- 
ing to  deflect  this  layer  of 
perirenal  fat  outward  and 
downward,  so  that  at  the 
conclusion  of  the  opera- 
tion it  will  form  a  cushion 
below  and  to  the  outside 
of  the  sutured  kidney. 

After  the  fatty  capsule 
is  torn  through,  the  kid- 
ney as  a  rule  comes  into 
view.  If  not,  it  is  either 
below  the  field  of  opera- 
tion or  it  has  slipped  up 
under  the  ribs.  When 
the  kidney  is  very  mov- 
able and  the  Edebohls 
pad  is  used,  it  is  not 
uncommonly  displaced 
downward  toward  the 
pelvis.  Rolling  the  pa- 
tient on  the  pad  will 
sometimes  bring  the  kid- 
ney within  reach.  The 
kidney  is  drawn  out  by 
hooking  a  finger  under 
its  upper  pole,  teasing  it 
out  through  the  incision, 
upper  and  lower  poles,  and  lateral  surfaces, 
disturbed,  in  order  to  avoid  the  renal  vessels. 

Four  sutures  of  silk,  celluloidin  thread,  or  chromicized  catgut  are  used.  The 
principle  of  the  Brodel  stitch  is  employed,  but  the  sutures  take  in  a  larger  inverted 
V  than  is  shown  in  the  illustration  of  the  Brodel  method  (Fig.  868).  Two  sutures 
are  introduced  on  each  side  of  the  kidney,  preferably  by  means  of  a  straight  sewing- 
needle.     \^Tien  it  is  not  feasible  to  deliver  the  kidney,  the  sutures  can  be  passed 


Fig.  868. — The  Modified  Brodel  Sutures  Introduced. 
Securing  the  kidney  at  the   same  relative   position   as  in  Edebohls' 
nephropexy,  one  on  each  surface  of  the  kidney  at  the  upper  and  the  lower 
pole. 

The  fatty  capsule  is  stripped  off  from  its  external  border, 
The  region  of  the  hilum  is  best  not 


830  SURGERY    OF   THE   KIDNEY. 

better  with  a  curved  needle  and  a  needle-holder.  As  a  general  rule,  the  sutures  are 
passed  while  the  kidney  is  lying  outside.  The  ends  of  each  suture  are  caught 
with  an  artery  forceps.  The  kidney  is  now  replaced,  taking  care  to  see  that  there 
is  no  twisting  of  the  pedicle.  It  is  best  at  this  stage  to  allow  a  part  of  the  air  to 
escape  from  the  nephrorrhaphy  pad,  in  order  to  lessen  intra-abdominal  pressure. 

The  ends  of  the  kidney  sutures  are  now  passed  with  a  carrier  from  within  out- 
ward through  the  lumbar  muscles,  the  upper  sutures  being  inserted  as  close  to  the 
last  rib  as  possible.  Two  sutures  are  passed  through  each  side  of  the  wound  and 
the  knots  are  tied  just  external  to  the  deep  fascia.  Between  each  pair  of  fixation 
sutures  a  chromicized  catgut  interrupted  suture  is  passed  to  close  the  wound  in  the 
lumbar  muscles,  and  additional  sutures  are  passed  below  the  level  of  the  last  fixation 
sutures  to  bring  together  the  lumbar  muscles  in  the  lower  part  of  the  incision.  The 
suture  which  is  immediately  below  the  level  of  the  kidney  catches  the  perirenal  fat, 
which  is  made  to  serve  as  a  pad  or  bolster  upon  which  the  kidney  may  rest  and  at 
the  same  time  closes  the  loose  pouch  into  which  the  kidney  was  displaced.  The 
subcutaneous  fat  is  sutured  with  continuous  catgut,  care  being  taken  to  approxi- 
mate the  deep  fascia  and  thus  insure  a  firm  line  of  union.  The  margins  of  the  skin 
incision  are  united  with  an  intracuticular  catgut  suture. 

Two  points  are  of  sufficient  importance  to  warrant  emphasis.  Complete 
hemostasis  should  be  secured  and  care  should  be  taken  lest  the  fixation  sutures  con- 
strict the  ilio-inguinal  and  the  iliohypogastric  nerves,  an  accident  which  gives  rise 
to  post-operative  pain. 

Decortication  of  the  Kidney  for  Chronic  Bright's  Disease. — Edebohls^ 
has  recommended  decortication  of  the  kidney  for  chronic  Bright's  disease.  The 
visible  changes  produced  by  this  lesion  he  found  in  the  adhesions  of  the  capsule  and 
in  the  nodulation  and  the  granular  condition  of  the  subcapsular  surface.  There 
were  also  variations  in  the  density  and  the  hardness  of  the  kidney  substance,  often 
varying  widely  in  different  parts  of  the  organ. 

He  found  at  secondary  operations  upon  kidneys  previously  suspended  that  there 
was  a  great  increase  in  the  vascular  supply  of  the  kidney  from  the  adhesions  which 
had  formed  between  its  capsule  and  the  surrounding  tissues.  He  believes  that  the 
basic  factor  in  the  improvement  or  the  cure  of  chronic  Bright's  disease  following 
decapsulation  lies  in  this  artificial  hypervascularization  of  the  kidney.  It  leads  to 
the  "gradual  absorption  of  the  interstitial  or  intertubular  inflammatory  products 
and  exudates,  thus  freeing  the  tubules  and  glomeruli  of  external  compression,  con- 
striction, and  distortion,  and  permitting  the  re-establishment  in  them  of  a  normal 
circulation." 

Edebohls  has  had  fifty-one  cases;  nine  patients  apparently  were  permanently 
cured  for  periods  varying  from  one  year  and  nine  months  up  to  ten  years;  seventeen 
patients  died  within  seven  days  of  the  operation. 

^Edebohls,  George  M.:  "A  Cure  of  Chronic  Bright's  Disease  by  Operation,"  Med.  Record, 
Dec.  21,  1901,  vol.  Ix,  p.  961;  "Renal  Decapsulation  for  Chronic  Bright's  Disease,"  Med.  Record, 
Mar.  28,  1903,  vol.  Ixiii,  p.  481. 


SURGICAL   TREATMENT    OF    DISEASES    OF   THE   KIDNEY. 


831 


This  operation  is  still  under  trial;  it  cannot  be  stated  at  present  that  decortica- 
tion of  the  kidney  will  find  a  permanent  place  in  the  therapy  of  chronic  Bright's 
disease. 

The  technic  of  the  operation  is  the  same  as  for  nephropexy  until  the  kidney  has 
been  delivered  through  the  wound.  The  fibrous  capsule  of  the  kidney  is  then 
divided  along  the  entire  length  of  the  convex  external  border  and  around  the  ex- 
tremity of  either  pole.  "Each  half  of  the  capsule  proper  is  in  turn  stripped  from 
the  kidney  and  reflected  toward  the  pelvis  until  the  entire  surface  of  the  kidney  lies 
raw  and  denuded  before  the  operator.  Care  must  be 
exercised  not  to  break  or  tear  away  parts  of  the  kidney. 
The  stripped-off  capsule  is  entirely  cut  away  close  to  its 
junction  with  the  pelvis  and  removed.  If  the  kidney  can- 
not be  delivered,  the  capsule  must  be  peeled  off  by  the 
fingers  in  the  bottom  of  the  wound  and  excised  as  far  as 
possible,  any  remaining  part  l)eing  simply  reflected  back- 
ward around  the  hilus,  where  it  will  curl  up  and  remain. 
The  kidney  is  dropped  back  into  its  fatty  bed  and  the 
external  incision  is  closed.  Drainage,  except  when  the 
parts  are  extremely  edematous,  is  dispensed  with." 

Edebohls  has  recently  recommended  renal  decapsula- 
tion also  for  puerperal  eclampsia,  and  has  reported  two 
recoveries  following  the  operation. 

Nephrotomy. — The  kidney  may  be  exposed  for  neph- 
rotomy by  Edebohls',  Morris',  Kelly's,  or  Robson's  inci- 
sion. In  an  adipose  subject  with  a  very  much  enlarged 
kidney,  Israel's  incision  may  be  used.  The  purposes  of 
nephrotomy  are  to  explore  and  drain  the  kidney,  to  relieve 
excessive  kidney  tension,  and  to  give  exit  to  the  urine  in 
cases  of  obstructive  anuria. 

After  exposure  the  fatty  capsule  should  be  separated 
everywhere  from  the  capsule  proper  of  the  kidney,  the 
dissection  advancing  on  either  aspect  and  around  both 
poles  until  the  pelvis  is  reached.  If  the  colon  is  distended, 
it  may  bulge  into  the  wound  and  get  into  the  way  of  the 
operator.  This  difficulty  is  readily  overcome  by  pushing  the  bowel  back  with  a 
sponge  and  holding  it  there  with  a  deep  retractor.  It  is  desirable  to  deliver  the  kid- 
ney through  the  incision,  and  in  cases  uncomplicated  by  inflammatory  changes  in 
the  perirenal  tissues  this  presents  no  difficulty.  The  delivery  of  the  kidney  may  be 
facilitated  by  gentle  traction  on  the  fatty  capsule  at  the  lower  pole,  by  hooking  the 
finger  beneath  the  upper  pole,  and  by  pulling  the  patient  downward  on  the  Edebohls 
cushion. 

After  the  organ  is  brought  outside  the  incision  its  configuration,  the  regularity 
of  its  surface,  and  its  color  should  be  noted.     The  pelvis  and  the  upper  extremity 


Fig.  866. — Position  of  the 
nephrotomy  incision  as  seen 
from  the  external  surface  of 
the  kidney;  b...b',  indicates 
the  position  of  the  columns 
of  Bertini;  a.  .  .a',  the  outer 
convex  border  of  the  kidney; 
c.  .  .c',  the  correct  line  of 
incision  immediately  poste- 
rior to  the  outer  convex  bor- 
der. 


832 


SURGERY    OF   THE    KIDNEY. 


Fig.  867. — Showing  the  Cor- 
rect AND  THE  Incorrect 
Direction  of  a  Nephro- 
tomy Incision. 

The  line  e d.   cuts  the 

most  vascular  area,  and  enters 
the     anterior     row    of    calyces. 

The  line  c x.  opens  into  the 

posterior  row,  freely  exposes 
the  anterior  row,  and  divides 
the  kidney  in  its  avascular  part. 


of  the  ureter  should  be  exposed  and  palpated.  To  de- 
termine the  presence  of  a  stone  or  a  deeply  lying  cyst, 
abscess,  or  tumor  of  the  kidney,  palpation  between  the 
two  hands  may  be  sufficient.  Small  lesions  may  escape 
observation.  The  use  of  an  exploring  needle  at  the 
present  time  is  considered  bad  practice  in  cases  of  stone, 
although  it  may  be  used  to  determine  the  character  of  the 
contents  of  a  cystic  tumor.  In  doubtful  cases  suspected 
of  stone,  tumor,  or  tuberculous  focus,  the  kidney  should 
be  deliberately  split  by  an  incision  through  Brodel's  white 
line  (Figs.  840,  866, 867,  868).  By  this  means  the  kidney 
is  divided  through  its  least  vascular  area.  During  the 
procedure  the  amount  of  hemorrhage  can  be  reduced  to 
the  minimum  by  compression  of  the  renal  vessels  at  the 
hilus  of  the  kidney. 

Brodel's  incision  opens  directly  into  the  posterior  row 
of  calyces  and  exposes  the  anterior  row  to  sight  and  to 
palpation,  so  that  a  stone  or  any  other  lesion  can  scarcely 
be  overlooked.  The  upper  extremity  of  the  ureter  may 
be  sounded  for  stone,  although  care  should  be  taken 
lest  a  small  calculus  become  impacted  in  the  ureter. 

Nephrotomy  may  be  very  difficult  when  there  has 

been  a  fibrosclerotic  inflammation  of  the  fatty  capsule.     In  these  cases  the  kidney 

is  sometimes  fixed  as  if  it  were  set  in  plaster-of- 

Paris,  so  that  separation  of  the  fatty  capsule  from 

the  organ  is  practically  impossible,  and  any  forcible 

attempts  to  do  so  would  be  associated  with  great 

danger  of  tearing  the  neighboring  organs  or  of 

lacerating  the  large  blood-vessels  in  the  vicinity. 

Under  such  circumstances  the  best  plan  is  to  cut 

directly  through  the  sclerosed  fatty  tissue  until  the 

kidney  itself  is  reached.     Hemorrhage  is  likely  to 

be  free,  and  may  be  controlled  either  by  the  use 

of  sutures  or  by  gauze  packing.     If  practicable, 

the  kidney  incision  should  be  just  sufficient  to 

admit  the  index-finger,  which  will  then  act  as  a 

tampon  during  exploration  of  the  organ. 

Another  difficulty  in  nephrotomy  is  caused  by 

a  distention  or  an  enlargement  of  the  kidney,  so 

that  it  extends  up  under  the  ribs.     The  capsule 

of  the  kidney  sac  in  cases  of  hydronephrosis,  pyo- 
nephrosis, cystic  disease,  etc.,  is  sometimes  so  thin 

that  it  may  be  ruptured  during  the  operative  manipulations.    The  possibility  of  rup 


Fig.    868. — The    Nephrotomv    Incision 
Complete. 
Showing  the  posterior  calyces  opened, 
affording    easy    access    to    the    anterior 
calyces. 


SURGICAL   TREATMENT    OF   DISEASES    OF   THE    KIDNEY. 


833 


ture  will  be  lessened  and  delivery  will  be  facilitated  by  aspiration  of  the  fluid  before 
attempting  to  separate  the  kidney  from  its  fatty  capsule.  In  some  cases  it  will  be  of 
considerable  advantage  to  resect  the  twelfth  rib.  To  do  this  a  vertical  incision  is 
made  upward  from  the  primary  incision.  There  is  no  danger  of  wounding  the 
pleura  if  the  periosteum  is  divided  along  the  posterior  surface  of  the  rib  and  the 
line  of  incision  is  kept  close  to  the  bone  itself,  stripping  off  the  periosteum  as  the 
anterior  surface  of  the  rib  is  approached  (Fig.  871).  The  nephrotomy  incision  in 
the  case  of  a  distended  kidney  should  be  at  the  thinnest  part  of  the  sac ;  secondary 
incisions  may  be  made,  if  necessary. 

The  course  of  a  nephrotomy  operation  after  exposure  of  the  kidney  depends  upon 
the  lesions  which  are  found.  Thus 
the  nephrotomy  may  at  once  become 
a  nephrolithotomy  or  a  nephrectomy 
or  a  partial  nephrectomy.  For  the 
technic  of  these  procedures  the 
reader  is  referred  to  the  appropriate 
sections.  If  it  is  desirable  to  main- 
tain drainage  of  the  renal  pelvis,  as 
in  the  case  of  an  insuperable  ob- 
struction of  the  ureter,  and  nephrec- 
tomy is  contraindicated  by  the  con- 
dition of  the  second  kidney,  the 
operation  of  nephrotriesis  and  the 
formation  of  a  permanent  fistula 
should  be  employed.  If  the  kidney 
is  infected,  drainage  by  means  of 
gauze  and  rubber  tubing  should 
be  instituted.  In  clean  cases  the 
divided  parts  of  the  kidney  are 
brought  together  by  catgut,  the  su- 
tures being  introduced  from  side  to 
side  by  means  of  a  round-pointed 
needle  (see  Fig.  869).  When  a 
permanent   fistula    is    made,    or   in 

cases  which  are  drained,  the  pressure  of  the  drainage-tube  and  packing  will  usually 
control  the  bleeding.  In  clean  cases  a  suture  serves  the  double  purpose  of  ap- 
proximating the  wound  in  the  kidney  and  of  arresting  the  hemorrhage.  In  clean 
cases  the  external  wound  should  be  closed. 

Nephrotriesis. — Nephrotriesis  is  the  name  given  by  Morris  to  the  operation  for 
establishing  a  more  or  less  permanent  fistula;  it  is  indicated  when  an  obstruc- 
tion to  the  outflow  of  urine  is  apt  to  be  prolonged  or  constant.  The  first  part  of 
the  operation  is  essentially  like  nephrotomy.  The  edges  of  the  kidney  incision 
are  stitched  either  to  the  borders  of  the  parietal  muscles  or  to  the  divided  edges 
VOL.  II — 53 


Fig.  869. — Metiioj)  of  1'assi.\(,  tiif.  Sutures  after  Asep- 
tic Nephrotomy. 
a,  Suture  uniting  the  margins  of  the  divided  calyces; 
b  and  c,  through-and-through  sutures  passed  with  a 
round-pointed  needle  approximating  the  cut  surfaces  of  the 
kidney  tissue  proper;  d,  suture  uniting  the  fibrous 
capsule. 


834 


SURGERY    OF   THE   KIDNEY. 


of  the  skin.  The  hemorrhage  may  be  controlled  by  hot  antiseptic  solutions  or 
by  gauze  packing.  The  renal  edges  should  not  be  united  to  the  skin  unless  it  is 
desired  to  make  the  fistula  permanent. 

Nephrolithotomy. — The  kidney  may  be  exposed  by  Morris',  Robson's,  or  Is- 
rael's incision.  It  should  be  separated  from  its  fatty  capsule  and  delivered  through 
the  incision,  if  possible.  Adhesions  between  the  fatty  capsule  and  the  kidney  should 
be  carefully  separated  by  snipping  them  with  scissors  rather  than  by  forcible  blunt 
dissection,  as  the  latter  involves  the  risk  of  tearing  the  kidney  tissue. 

It  may  be  necessary,  in  order  to  gain  more  room,  to  divide  the  lower  edge  of  the 
ligament  of  Henle,  which  forms  one  of  the  commonest  impediments  to  the  free  man- 
ipulation of  the  upper  pole  of  the  kidney.  It  is  surprising  to  see  how  much  diffi- 
culty is  avoided  if  this  structure  is  divided,  as  can  be  done  easily  by  means  of  a 


drAumh. 


Ext.  ohl 


Fig.  870. — Nephrectomy  for  Tuberculosis  after  Partial  Resection  of  the  Twelfth  Rib. 

Note  the  isolation  of  the  vessels  of  the  pedicle  and  the  ureter.     Such  a  dissection  of  the  pedicle  should  be  made, 

if  possible,  in  every  nephrectomy  before    the   ligatures  are  passed,  each  vessel  being  tied  separately. 

probe-pointed  bistoury.  The  finger  guiding  the  bistoury  should  press  the  tissues 
away  from  the  upper  part  of  the  wound,  so  that  there  is  less  danger  of  wounding  the 
pleura. 

After  the  kidney  is  delivered  or  the  attempt  to  deliver  it  has  failed,  the  entire 
organ  and  the  ureter  should  be  carefully  palpated  to  determine  the  position  of  the 
stone.  A  single  stone  in  the  cortex  may  be  removed  by  a  simple  incision  directly 
over  it  through  the  renal  parenchyma.  Stones  lying  entirely  within  the  kidney 
pelvis  may  be  removed,  if  they  are  small,  by  an  incision  which  does  not  involve  the 


SURGICAL   TREATMENT   OF   DISEASES    OF   THE    KIDNEY.  835 

kidney  parenchyma.  If  repeated  a:-ray  examination  and  direct  palpation  have 
certainly  determined  the  number  and  the  position  of  the  stones,  one  or  more  in- 
cisions may  be  made  directly  over  them. 

In  a  large  number  of  cases,  however,  a  complete  hemisection  of  the  kidney  will 
render  the  operation  easier  and  there  will  be  less  likelihood  of  leaving  stones  behind. 
During  incision,  which  it  is  best  to  make  along  Brodel's  white  line,  the  pedicle 
(renal  artery  and  veins)  should  be  compressed  by  an  assistant.  The  upper  end 
of  the  ureter  should  be  palpated  for  stone  rather  than  sounded,  because  stones  are 
easily  impacted  in  that  situation. 

A  stone  may  be  removed  by  the  finger,  scoop,  curet,  or  a  pair  of  slender  forceps. 
Large  branching  stones  in  the  calyces  and  the  pelvis  will  sometimes  need  to  be 
crushed  before  removal.  This  should  be  avoided  when  possible,  in  order  to  lessen 
the  chance  of  leaving  a  fragment  of  stone  behind.  Care  should  be  taken  to  tear 
the  kidney  parenchyma  as  little  as  possible.  Following  the  extraction  of  a  stone,  it 
is  advised  by  White  and  Martin  to  flush  the  kidney  and  the  calyces  with  a  stream 
of  normal  saline  solution,  flowing  under  strong  pressure  from  a  comparatively  large 
nozzle  introduced  through  the  kidney  wound.  This  is  especially  valuable  when 
the  stone  has  been  fractured  or  numerous  small  stones  are  present.  Sometimes  a 
small  stone  or  a  fragment  will  be  removed  in  this  way  which  otherwise  would  be 
overlooked. 

If  the  case  is  a  clean  one  and  there  has  been  little  laceration  of  the  kidney  paren- 
chyma, the  operation  may  be  completed  by  bringing  together  the  incised  surfaces 
of  the  kidney  with  sutures.  Incisions  into  the  renal  pelvis  should  be  closed  with 
fine  Lembert  sutures  of  catgut  including  only  the  outer  coats.  If  silk  is  used,  it 
must  not  penetrate  the  mucous  membrane,  lest  it  form  the  nidus  for  a  stone.  If  the 
kidney  has  been  much  damaged,  or  if  there  is  any  indication  of  infection,  drainage 
must  be  used.  In  clean  cases  when  the  kidney  wounds  are  satisfactorily  approxi- 
mated the  external  incision  may  be  closed  without  drainage,  but  when  there  is  some 
doubt  about  asepsis,  and  in  order  to  provide  against  the  possibility  of  urinary  leakage, 
it  is  well  to  place  a  small  drain  through  the  external  wound  and  leave  it  there  for 
twenty-four  to  thirty-six  hours. 

The  dangers  of  nephrolithotomy  are  hemorrhage,  cellulitis,  renal  abscess,  renal 
fistula,  uremia,  anuria,  lumbar  hernia,  and  wound  of  the  pleura,  colon,  and  peri- 
toneum. 

Hemorrhage  usually  may  be  controlled  by  direct  compression  of  the  pedicle  of 
the  kidney,  by  mattress  sutures  passed  through  the  kidney  parenchyma,  by  irriga- 
tion with  a  hot  aseptic  solution,  or  by  gauze  packing.  Cellulitis  is  rare  if  an  aseptic 
technic  is  preserved  and  drainage  is  provided  in  septic  cases.  In  Morris'  hands 
renal  fistula  followed  in  5  per  cent,  of  nephrolithotomies;  it  was  never  permanent. 
The  condition  of  the  opposite  kidney  is  a  question  of  much  concern  on  account  of 
the  frequency  of  bilateral  nephrolithiasis,  and  its  functional  activity  is  always  more 
or  less  a  matter  of  doubt.     Lumbar  hernia  is  uncommon,  and  is  guarded  against 


836  SLTIGERY    OF   THE    KLDXEY. 

by  careful  closure  of  the  wound.  There  is  little  danger  of  wounding  the  pleura  if  its 
relations  to  the  twelfth  rib  are  borne  in  mind. 

Nephrectomy. — Nephrectomy  may  be  total  or  partial,  pericapsular  or  sub- 
capsular. Pericapsular  nephrectomy  is  that  form  of  operation  in  which  the  organ 
is  removed  with  its  fibrous  capsule  intact.  In  subcapsular  nephrectomy  the  kidney 
is  enucleated  from  within  its  fibrous  capsule,  which  is  left  behind. 

The  kidney  is  exposed  by  means  of  Morris',  Israel's,  Robson's,  or  Kelly's  in- 
cision. It  is  freed  from  the  surrounding  tissues  and  delivered  through  the  incision. 
The  vessels  of  the  pedicle  are  then  isolated,  and  a  ligature  is  thro\\Ti  around  them 
by  means  of  an  aneurysm  needle.  This  ligature  should  not  include  the  ureter.  In 
all  cases  it  is  wise  to  isolate  and  to  apply  separate  ligatures  to  the  vessels  (Fig.  870), 
and  this  is  particularly  true  if  the  pedicle  is  thick  from  the  presence  of  fatty  tissue. 
After  dividing  the  vessels  well  to  the  renal  side  of  the  ligature,  the  ureter  is  separated 
as  far  down  as  desirable  and  divided  between  two  ligatures,  the  exposed  mucosa  of 
the  lower  portion  being  carefully  disinfected  with  carbolic  acid  and  alcohol. 

The  technic  described  is  that  which  will  o]:)tain  in  simple  uncomplicated  cases. 
When  there  is  difficulty  in  separating  the  kidney  from  its  surrounding  structures 
with  the  finger,  it  is  better  to  employ  the  scissors  or  the  knife  than  to  do  much  tearing. 
In  case  the  pedicle  of  the  kidney  is  short  and  surrounded  by  much  inflammatory 
exudate,  and  in  the  case  of  a  kidney  tumor,  it  is  sometimes  advisable  to  clamp  the 
pedicle  and  divide  it  toward  the  renal  side  before  attempting  to  deliver  the  kidney; 
but  whenever  it  is  possible  the  renal  vessels  should  be  ligated  before  they  are  divided 
in  order  to  make  a  clean  excision  of  the  kidney  and  to  avoid  slipping  of  the  ligatures. 
The  delivery  of  the  kidney  is  sometimes  facilitated  by  inserting  the  fingers  of  tho 
left  hand  beneath  the  lower  ribs  and  forcibly  pulling  them  up.  At  times  a  resection 
of  the  twelfth  rib  will  be  of  great  assistance  (Fig.  871).  When  the  kidney  is  cystic 
and  verv  much  enlarged,  it  will  expedite  matters  to  aspirate  the  tumor  before  at- 
tempting to  deliver  it. 

Care  should  be  taken  during  nephrectomy  lest  the  peritoneum  or  the  colon  be 
torn.  If  either  of  these  accidents  occur,  the  rent  should  be  immediately  closed  with 
sutures.  One  of  the  greatest  dangers  incident  to  a  nephrectomy  is  an  overstretch- 
ing of  the  pedicle.  It  may  result  in  a  rupture  of  the  vessels  or  in  the  slipping  of  a 
ligature  which  has  been  applied  to  them.  To  avoid  these  accidents,  when  the 
structures  at  the  hilus  of  the  kidney  are  very  much  fixed,  the  pedicle  should  be 
clamped  and  divided  on  its  renal  side  before  the  kidney  is  delivered. 

Suhcapsidar  iiephrectomy  is  indicated  in  those  cases  in  which  the  fatty  capsule  of 
the  kidney  is  so  altered  by  long-conTinued  inflammation  that  it  is  extremely  difficult 
or  even  impossible  to  separate  it  from  the  fibrous  capsule  of  the  kidney  without  great 
risk  of  injuring  adjacent  viscera,  and  more  especially  the  vena  cava  or  other  great 
veins.  The  operation  should  be  avoided  in  tuberculosis  of  the  kidney  and  in  the 
case  of  malignant  tumors,  as  in  such  cases  the  fibrous  capsule  is  almost  necessarily 
involved. 

The  fatty  capsule  is  exposed  in  the  usual  manner  and  divided.     The  fibrous 


SURGICAL   TREATMENT   OF   DISEASES    OF   THE    KIDNEY. 


837 


capsule  is  then  incised  along  the  convex  border  of  the  kidney  for  its  entire  length. 
WTien  feasible,  the  kidney  is  separated  from  its  fibrous  capsule  by  blunt  dissection 
with  the  fingers  or  gauze.  In  many  cases  the  capsule  comes  off  without  difficulty. 
When  the  capsule  has  been  detached  down  to  the  hilum,  the  pedicle  may  be  treated 
in  either  of  two  ways :  It  may  be  clamped  with  heavy  curved  forceps  and  the  kidney 
cut  away,  after  which  the  vessels  may  be  ligated  separately,  as  seen  in  the  pedicle; 
or,  the  pedicle  may  be  transfixed  with  a  pedicle  needle  carrying  two  ligatures  and 
each  half  of  the  pedicle  tied  separately.     When  this  plan  is  followed,  it  is  best  to 


Fig.  871. — Resection  of  Twelfth  Rib  in"  Nephrectomy  (after  T.  S.  Cullen). 
The  edge  of  the  latissimus  dorsi  has  been  located  and  then  the  muscle  has  been  severed  directly  over  the 
rib  and  drawn  to  either  side.     The  rib  and  the  superior    lumbar    trigonum  are  thus  exposed.      The  periosteum 
of  the  rib  is  incised  as  indicated  bj'  the  dotted  line,  and  the  bone  shelled  out  and  removed. 

leave  the  ligatures  long  and  to  catch  the  pedicle  with  forceps  before  cutting  away  the 
kidney,  after  which  the  individual  vessels  should  be  separately  ligated. 

The  ligation  of  the  vessels  in  subcapsular  nephrectomy  is  much  less  satisfactory 
than  in  typical  nephrectomy,  because  of  the  inclusion  of  the  kidney  pelvis, 
which  may  be  infiltrated.  When  there  is  much  infiltration  of  the  structures  about 
the  renal  pelvis,  it  is  better  to  break  through  the  tissues  of  the  pelvis  and  to  sep- 
arate it  from  the  renal  vessels,  and  to  tie  the  vessels  separately.  After  the  kidney 
has  been  cut  away,  as  much  of  the  fibrous  capsule  and  pelvis  of  the  kidney  as  can 
safely  be  detached  should  be  trimmed  off.     When  the  kidney  has  been  removed, 


838  SURGERY    OF   THE    KIDNEY. 

with  the  additional  exposure  afforded  much  of  the  fibrous  capsule  and  pelvis  of 
the  kidney  can  often  be  excised.  This  procedure  lessens  the  chances  of  the  forma- 
tion of  a  cyst,  which  is  an  occasional  after-complication  of  subcapsular  nephrectomy. 

At  times  it  will  be  found  impossible  to  detach  the  kidney  as  a  whole  from  its 
capsule.  In  such  cases  the  fingers  are  plunged  directly  into  the  kidney  tissue  and 
the  organ  is  removed  piecemeal  from  within  outward  by  breaking  though  the  kidney 
parenchyma  and  removing  one  portion  after  another  from  within.  In  such  cases 
more  or  less  renal  tissue  may  be  left  adherent  to  the  fibrous  capsule  and  more  or  less 
of  it  may  remain  as  a  part  of  the  pedicle  at  the  hilum.  The  ligation  of  the  pedicle 
must  be  varied  to  suit  the  conditions  in  the  particular  case,  following  the  principles 
already  laid  down  for  subcapsular  nephrectomy. 

Abdominal  nephrectomy  is  used  when  the  patient  is  very  fat,  when  there  is  a 
lateral  deformity  of  the  spine,  and  in  the  case  of  large  tumors.  It  is  also  of  advantage 
if  the  condition  of  the  second  kidney  is  a  matter  of  doubt. 

The  operation  should  be  begun  by  Langenbuch's  incision.  After  determining 
the  presence  and  the  condition  of  the  second  kidney,  the  outer  layer  of  the  meso- 
colon on  the  affected  size  is  torn  through  and  the  kidney  exposed.  The  outer  layer 
of  the  mesocolon  is  avascular,  the  nutrient  vessels  of  the  colon  being  placed  in  the 
inner  layer.  The  kidney  is  separated  from  its  surrounding  tissues  and  the  pedicle 
is  tied  and  divided  just  as  in  lumbar  nephrectomy.  In  an  abdominal  nephrectomy 
for  tumor,  if  exposure  of  the  pedicle  is  feasible,  it  should  be  clamped  or  tied  before 
there  has  been  much  manipulation  of  the  kidney.  If  drainage  is  required,  a  secon- 
dary incision  should  be  made  through  the  loin.  The  tear  in  the  mesocolon  need  not 
be  sutured  unless  there  is  some  infection  of  the  kidney.  The  ureter  should  be 
divided  as  low  down  as  possible. 

When  it  is  especially  important  to  control  the  pedicle  promptly  and  to  provide 
drainage,  Morris  adopts  lumbo-abdominal  nephrectomy.  In  this  operation,  after 
opening  the  abdomen  and  examining  the  opposite  kidney,  a  piece  of  gauze  is 
spread  over  the  diseased  organ  from  inside  the  abdomen  and  the  primary  incision  is 
temporarily  closed.  A  lumbar  exposure  is  now  made,  the  posterior  surface  of  the 
kidney  is  carefully  separated  from  its  attachments,  and  the  wound  is  plugged  with 
gauze.  The  laparotomy  incision  is  reopened,  the  peritoneum  at  the  outer  side  of 
the  colon  is  torn  through,  and  the  pedicle  is  at  once  isolated  and  tied  before  the 
separation  of  the  kidney  is  completed.  Delivery  of  the  tumor  through  the  abdom- 
inal incision  may  be  assisted  by  pressing  it  forward  through  the  lumbar  wound.  A 
sudden  tearing  away  of  the  tumor  should  be  especially  avoided,  for  in  one  case  re- 
ported by  Morris  this  resulted  in  a  serious  hemorrhage  from  the  rupture  of  a  large 
vein  which  crossed  the  tumor.  The  operation  is  completed  by  closing  the  abdominal 
incision  and  allowing  the  gauze  pack  in  the  lumbar  opening  to  remain  as  drainage. 
If  the  presence  and  the  condition  of  the  second  kidney  have  been  determined  before- 
hand, the  lumbar  incision  may  be  made  first.  ^Mienever  possible  abdominal 
nephrectomy  should  be  avoided,  as  the  retroperitoneal  lumbar  operation  is  much  the 
safer,  especially  in  inflammatory  cases. 


SURGICAL   TREATMENT   OF   DISEASES    OF   THE   KIDNEY.  839 

Partial  nephrectomy  is  done  for  lesions  which  are  hmited  to  one  area  of  the  kidney. 
Morris  has  done  the  operation  in  ten  cases  and  Kelly  has  recently  reported  a  number 
of  others.  The  kidney  is  exposed  in  the  usual  way  and  delivered,  and  the  vessels 
at  the  hilum  are  compressed  while  the  excision  is  made.  The  line  of  excision  should 
be  such  that  the  section  of  renal  tissue  removed  is  wedge-shaped;  this  facilitates  the 
closure  of  the  wound.  AMien  a  transverse  or  an  oblique  incision  is  obligatory,  the 
surface  must  be  left  to  granulate.  The  sutures  should  be  passed  in  accordance 
with  the  principle  devised  by  Brodel,  already  described. 

Nephro-ureterectomy. — Xephro-ureterectomy  is  a  combination  of  the  opera- 
tions of  nephrectomy  and  ureterectomy.  It  is  indicated  especially  in  cases  of  tuber- 
culosis of  the  kidney  and  ureter. 

For  the  details  of  the  operation  see  Chapter  XLIII,  page  744. 


INDEX. 


Abbe's    method   of    cutting 

esophageal  strictures,  364 
Abdomen,  foreign  bodies  left 
in,  after  operation,  56 
penetrating  wounds,  639 
abstract   of  literature, 

648 
after-treatment,  644 
contraindications      to 

operation,  646 
diagnosis,  640 
drainage  in,  644 
enterorrhaphy  in,  ab- 
stract of  literature, 
651 
hemorrhage  from  liver 

in,  treatment,  643 
history,  639 
gastrorrhaphy  in,  ab- 
stract of  literature, 
651 
injuries  to  bladder  in, 
treatment,  643 
to  kidney  in,  treat- 
ment, 644 
to       pancreas       in, 

treatment,  643 
to  spleen  in,  treat- 
ment, 643 
prognosis,  645,  652 
symptoms,  652 
treatment,  641 
Abdominal     cavity,     disten- 
tion, by  artificial  means, 
prevention  of  post-oper- 
ative intestinal  adhesions 
by,  464 
incision  in  Cesarean     sec- ' 

tion,  90 
incision,   separation,   post- 
operative, 53 
treatment,  54 
nephrectomy,  838 
pregnancy,  158 
section,     exploratory,     for 
puerperal  sepsis,  128 
for    intraperitoneal     ab- 
scess, and  diffuse  sup- 
purative      peritonitis, 
121 
for      puerperal       sepsis, 

indications,  118 
in  extrauterine  preg- 
nancy, 169 
surgery,  drainage  in,  712. 
See  also  Drainage  in  ab- 
dominal and  'pelvic  sur- 
gery. 


Abdominal  wall,  emphysema, 
post-operative,  55 
sloughing,       post-opera- 
tive, 55 
Abdomino-perineal  operation 
for    malignant    tumors    of 
rectum,  486 
Abortion,  tubal,  150 
Abscess,  appendical,  compli- 
cating      appendicitis, 
treatment,  537 
drainage  of,  721 
cavity,  cleansing,  in  appen- 
dicitis, 539 
intraperitoneal,  abdominal 

section  for,  121 
of     Bartholin's     gland     in 
pregnancy,  operation  for, 
115 
of     breast,     incision     and 

drainage,  256 
of  kidney,  774 
of  hver,  309 

comi^licating  appen- 

dicitis, 523 
treatment,  540 
etiology,  309 
pain  in,  310 
prognosis,  310 
symptoms,  309 
treatment,  310 
of     lungs,     post-operative, 

41 
of  spleen,  612 

treatment,  613 
pancreatic,  567 

treatment,  580 
pelvic,         opening        into 

rectum,  465 
periappendicai,    from    ap- 
pendicitis, 520 
subphrenic,  314 

complicating       appendi- 
citis. 522 
complicating       appendi- 
citis, treatment,  540 
diagnosis,  316 
prognosis,  316 
symptoms,  315 
treatment,  317 
vaginal    puncture,      drain- 
age after,  720 
Acetonuria,  post-operative, 13 
Acid    intoxication    in    cyclic 
vomiting   in    children, 
13 
post-operative,  13 
lactic,  in  stomach,  320 
841 


Aciduria,  post-operative,  13 
Acne  pancreatica,  569 
Actinomycosis    of    intestine, 
425 
treatment,  426 
of    vermiform       appendix, 
553 
treatment,  554 
Adenocarcinoma      basocellu- 
lare       adenoides       of 
breast,  226 
solidum  of  breast,  226 
comedo  of  breast,  225 
of  breast,  224 

beginning  in  a  cyst  with 
an    intracystic    papil- 
loma, 231 
circumscribed  form,  229 
colloid,  227 
cystic,  229 
diffuse  form,  230 
Adenocystoma  of  kidney,  814 
Adenofibroma  of  breast,  218 

pathology,  218 
Adenoma,   cystic,   of   breast, 
220 
of  intestine,  427 
of  kidney,  804 
of  nipple,  253 
of  pancreas,  591 
treatment,  591 
of  rectum,  472 
Adenosarcoma,  embryonic,  of 

kidney,  805 
Adherent  appendix,  removal, 

537 
Adhesions    complicating    ap- 
pendicitis, operative 
treatment,  537 
intestinal,  as  cause  of  post- 
operative intestinal  ob- 
struction, 26 
separation   of,   from   in- 
fected cysts  or  malig- 
nant tumors,  389 
peritoneal,  as  cause  of  ex- 
trauterine pregnancy, 131 
post-operative      intestinal, 
460.     See  also  Intestinal 
adhesions,         post-opera- 
tive. 
Adipocere  of  fetus  in  extra- 
uterine pregnancy. 159 
Adnexa  uteri,  drainage,   718 
inflammatory  diseases  of, 
and   appendicitis,   dif- 
ferentiation, 544 
Adrenal  tumors,  811 


842 


INDEX. 


Adynamic  ileus,  391 
symptoms,  403 
treatment,  412 
Afferent  nerve-supply,  injury 

to,  ileus  from,  410 
Ague-cake  spleen,  607 

splenectomy  for,  607 
Albert    -    Franck   -    Kocher 
method  of  gastrostomy,  366 
Albert-Franck's    method    of 

gastrostomy,  366 
AUingham's      operation     for 

hemorrhoids,  509 
Amebic     dysentery,     vermi- 
form appendix  affected  in, 
554 
American  operation  for  hem- 
orrhoids, 512 
Amoebae  dysenterise,  309 
Amputation     of     cervix    for 
hypertrophy  of  vaginal  por- 
tion, in  pregnancy.  111 
Amyloid  spleen,  615 
Anastomosis,    antiperistaltic, 
322 
intestinal,    433.     See    also 

Intestinal  anastomosis. 
isoperistaltic,  322 
Anemia  infantum,  598 
pseudoleukemia,  598 
secondary,      with     splenic 
tumor,  598 
Anesthesia  in  operations  for 
inguinal  hernia,  700 
local,  in  hernia  operations, 
673 
Anesthetics,    late    poisonous 

effects,  14 
Angioma       cavernosum       of 
spleen,  615 
of  breast,  213 
of  intestine,  427 
Anthrax,      intestinal     ulcers 

from,  424 
Antiperistaltic     anastomosis, 

322 
Anus,     artificial,     444.     See 
also  Colostomy. 
imperforate,  469,  470 
malformations,  468 
Apoplexy,  pancreatic,  564 

treatment,  580 
Appendical    abscess    compli- 
cating      appendicitis, 
treatment,  537 
drainage,  721 
Appendicitis,  514 

abscess  of  liver  complicat- 
ing, 523 
treatment,  540 
acute,  519 

adhesions        complicating, 
operative  treatment,  537 
and   cholecystitis,      differ- 
entiation, 531 
and    floating    kidney,    dif- 
ferentiation, 531 
and  inflammation  of  Meck- 
el's    diverticulum,     dif- 
ferentiation, 531 


Appendicitis   and    inflamma- 
tory    diseases    of    right 
adnexa  uteri,  differentia- 
tion, 544 
and    ovarian    tumor    with 
twisted    pedicle,    differ- 
entiation, 544 
and     pelvic    affections    in 
female,     differen- 
tiation, 530,  544 
incision  for  removal 

of  appendix,  545 
lateral  incision,  546 
relation,  543 
removal    of    appen- 
dix, 546 
treatment,  545 
and    pneumonia,    differen- 
tiation, 531 
and     pyelitis,     differentia- 
tion, 531 
and  ruptured  extrauterine 
pregnancy,      differentia- 
tion, 544 
and  stone  in  gall-bladder, 
differentiation,  531 
in   kidney,      differentia- 
tion, 531 
in  ureter,  differentiation, 
531 
and  tuberculosis  of  pelvic 
organs    in   female,    rela- 
tion, 544 
and  typhoid  fever,  differen- 
tiation, 531 
appendical  abscess  compli- 
cating,  treatment,  537 
as  local  expression  of  gen- 
eral infection,  527 
chronic,  523 

and  mucous  colitis,  rela- 
tion, 530 
symptoms  and  diagnosis, 
530 
cleansing  of  abscess  cavity, 

539 
complicating  hernia,  665 
labor,  548 
pregnancy,  548 

treatment,  549 
puerperium.  548 
diagnosis,  527 

differential,  530 
effect  of,  on  pregnancy,  549 
etiology,  525 
age,  525 
exciting,  525 
final       or      determining 

causes,  526 
foreign  bodies  and  con- 
cretions, 526 
pathogenic  bacteria,  526 
predisposing,  525 
generalized  peritonitis 

from,  521 
treatment,  541 
gridiron  incision  in,  534 
history,  514 

in     pregnancy,     operation 
for,  106 


Appendicitis    in   relation   to 

gynecologic  diseases,  543 
in  typhoid  fever,  550 

symptoms    and    diag- 
nosis, 551 
treatment,  551 
incision  in,  534 
McBurney's      incision     in, 

534 
median  incision  in,  534 
medical  treatment,  532 
operation,  532 

early,  532 

fistula   after,   treatment, 
542 

indications,  532 

intermediate,  533 

interval,  533 

late,  533 

preparation,  533 
of  abdomen,  534 

removal  of  appendix,  535 
ligation    of    mesen- 
tery in,  535 
treatment  of  stump 
in,  535 
operative   treatment,    532. 

See     also     Appendicitis, 

operation. 
periappendical  abscess 

from,  520 
portal  infection  complicat- 
ing, 523 
pulmonary  embolism  com- 
plicating, 523 
purulent   peritonitis   from, 

522 
pylephlebitis  complicating, 

523 
secondary  to  pelvic  inflam- 
mation in  female,  544 
semilunar  incision  in,  534 
septic  peritonitis  from,  521 
spreading  peritonitis  from, 
521 
treatment,  541 
subphrenic  abscess  compli- 
cating, treatment,  540 
symptoms,  527 

chills,  529 

constipation,  529 

fever,  528 

icterus,  529 

ileus,  529 

leukocytosis,  529 

muscle  spasm,  528 

pain,  527 

rigidity,  528 

tenderness,  528 

tumor,  529 

vomiting,  529 
thrombosis      complicating, 

523 
treatment,  medical,  532 

operative,     532.  See 

also  Appendicitis,  op- 
eration. 
tuberculous,  552 

treatment,  553 
urinalysis  in,  530 


INDEX. 


843 


Appendicostomy,  542 
Areola  and  nipple,  disease  of, 
251 
malignant  tumors,  253 
Arterial   embolism    of   brain, 
post-operative,  67 
of  intestine,     post-oper- 
ative, 66 
of    spleen    and    kidney, 
post-operative,  68 
rupture,     of    brain,     post- 
operative, 67 
thrombosis     of     intestine, 
post -operative,  66 
of    spleen    and    kidney, 

post-operative,  68 
post-operative,  61 
Arteries,  coronary,  of  heart, 
embolism,    post-op- 
erative, 67 
thrombosis,  post-oper- 
ative, 67 
Artery,  mesenteric,  embolism 
of,  ileus  from,  394 
renal,  751 
Artificial    anus,    444.         See 
also  Colostomy. 
fecal       fistula,       Kocher's 
method   of  making, 
443 
technic,  443 
Aseptic  wound  fever,  15 
Atrophy,  puerperal,  of  tube, 
as    cause    of    extrauterine 
pregnancy,  135 
Atropin-poisoning,  post- 

operative, 69 


Bacon's  operation  for  stric- 
ture of  rectum,  490 

Bacteria  in  gall-bladder,  279 
in  gall-stones,  279 
in  stomach,  321 
pathogenic,  local  infections 
due  to,  post-operative,  15 

Banti's  disease,  608 
etiology,  608 
symptoms,  608 
treatment,  608 

Bartholin's  gland,  abscess,  in 
pregnancy,  operation  for, 
115 

Bartlett's  treatment  of  in- 
guinal hernia,  711 

Bassini's  operation  for  in- 
guinal hernia,  710 

Bed-sores,  post-operative,  11 

Bertini's  columns,  752 

Bevan's  incision  for  gall- 
bladder and  gall-duct  oper- 
ation, 296 

Beyea  and  Penrose's  method 
of  nephropexy,  828 

Beyea's  method  of  gastro- 
pexy,  371 

Bile,  278 

in  gall-bladder,  279 

Bile-duct,  common,  stones  in, 
287 


Bile-ducts,  diseases,  etiology, 
278 
drainage,  722 
operations  on,  276 
history,  276 
Bladder,  blood-clots  in,  post- 
operative, 48 
diseases,       post-operative, 

42 
drainage,  730 
fistulas,         post-operative, 

52 
hemorrhage     from,     post- 
operative, 48 
hernia,  658 

injuries,      in      penetrating 
wounds      of      abdomen, 
treatment,  643 
penetrating     wounds,     ab- 
stract  of  literature,  650 
Blake's  principles  of  operative 
treatment    in    diffuse   sup- 
purative peritonitis,  726 
Blood,  cryoscopy  of,  in  kid- 
ney operations,  822 
examination    of,    in    diag- 
nosis of  diseases  of  stom- 
ach, 321 
in  stomach,   chemical  test 
for,  320,  322 
Blood-clots     in     bladder     or 
kidney,   post-operative,  48 
Bloodgood's     operation     for 

inguinal  hernia,  707 
Bodine's    method    of    colos- 
tomy, 446 
Bottomley's  method  of  treat- 
ing tuberculosis  of  perito- 
neum, 636 
Brachycardia,  post-operative, 

11 
Brain,      arterial      embolism, 
post-operative,  67 
rupture,    post-operative, 
67 
Breast,  abscess,  incision  and 
drainage,  256 
absence,  193 
adenocarcinoma,  224 

basocellulare    adenoides, 
226 
solidum,  226 
beginning  in  a  cyst  with 
an    intracystic    papil- 
loma, 231 
circumscribed  form,  229 
colloid,  227 
comedo,  225 
cystic,  229 
diffuse  form,  230 
adenofibroma,  218 

pathology,  218 
angioma,  213 
anomalies,  193 
areas    of    calcification    in, 

213 
benign    epithelial    tumors, 
220 
tumors,  212 
caked,  209 


Breast,  cancer  cysts,  246 
carcinoma,  222.      See  also 

Carcinoma  of  breast. 
cystadenoma,  200 
cystic  adenoma,  220 

disease,  200 
cysts,  246 

with    intracystic    papil- 
lomatous 
growths,  221 
discharge  of  blood 
from  nipple,  as 
symptom,  222 
dermoid  cysts,  214 
diseases,  180 

anatomic  and  histologic 

remarks,  182 
classification,  192 
clinical  picture,  185 
diagnosis,  185 
symptomatic,  193 
enchondroma,  213 
encysted  foreign  bodies  in, 

214 
fibroadenoma,  diffuse,  200 
fibro-epithelial  tumors,  214 
fibroma,  213 
galactocele,  196,  246 
gumma,  212 
hydatid  cysts,  214 
hypertrophy,  194 
diff'use  bilateral,  197 
in  pregnancy,  197 
in  virgin,  197 
senile     parenchymatous, 
200.      See  also  Hyper- 
trophy of  breast,  senile 
parenchymatous . 
infantile,      anatomic      and 
histologic  remarks,  182 
hypertrophy,  194 
interlobular  stroma,  182 
intra-acinous     cystic     epi- 
thelioma, 200 
intracanalicular    myxoma, 
214 
recurrent,  217 
spontaneous        disap- 
pearance, 217 
intralobular  stroma,  182 
involution,   abnormal,   200 
lactation  hypertrophy,  183, 
194 
and  tumors  of  breast, 
differentiation,  190 
lipoma,  213 
lymphatic  cysts,  248 
malignant     tumors,     diag- 
nosis, 185 
pain,      discharge      of 
blood    from    nipple, 
and    fluctuation    in 
diagnosing,  187 
medullary  carcinoma,  233. 
See    also    Carcinoma    of 
breast,  -medullary. 
multiple  tumors,  214 
myxoma,   intracanalicular^ 
214 
recurrent,  217 


844 


INDEX. 


Breast,  myxoma,  intracanal- 
icular,  spontaneous  dis- 
appearance, 217 
neuralgia,  193 
non-lactating,  mastitis  of, 

211 
normal,  anatomic  and  his- 
tologic remarks,  182 
osteoma,  213 
parenchyma,  182 
puberty  hypertrophy,  182, 

194 
sarcoma,   248.        See   also 

Sarcoma  of  breast. 
sarcomatous  cysts,  247 
senile,  185 
single  tumors,  large,  217 

small,  216 
supernumerary,  193 
tissue,  aberrant,  193 
tuberculosis,  211 
tumors,  age  of  onset,  189, 
190 
and    lactation    mastitis, 

differentiation,  190 
clinical  picture,  185 
cystic,  246 
diagnosis,  185 
duration,  189,  190 
excision  of  breast,  258 

of  tumor,  257 
exploratory   incision   for 

diagnosis,  257 
important    facts    to    be 
ascertained  in  history, 
189 
lactation  hypertrophy  of 
breast    and,    differen- 
tiation, 190 
large  single,  217 
multiple,  214 
excision,  257 
Warren's       operation, 
257 
operative  technic,  256 
position,  189 
preparations    for    opera- 
tions, 256 
small  single,  216 
symptoms  of  onset,  191 
trauma  as  etiologic  fac- 
tor, 190 
Bright's  disease,  chronic,  de- 
cortication  of  kidney   for, 
830 
Broad  ligament,  rupture  into, 

in  tubal  pregnancy,  156 
Brodel's  incision  in  nephrot- 
omy, 832 
suture  in  nephropexy,  827 
Bronchi,  post-operative  com- 
plications involving,  35 
Bronchitis,  acute,  post-oper- 
ative, 42 
Bronchopneumonia,         post- 
operative, 37 
Bubonocele,  697 
Bureau  and  Vignard's  method 
of     treating     rectovaginal 
fistula,  457 


Burns,  intestinal  ulcers  from, 
424 

post-operative,  53 
Button-holder,    Hartmann's, 

435 


Cachexia  as  sign  of  cancer 

of  breast,  188 
Cake  kidney,  753 
Caked  breast,  209 
Calcification,     areas     of,     in 

breast,  213 
Calculus  of  ureter,  733 

and  appendicitis,  differ- 
entiation, 531 
operative  treatment,  739 
pancreatic,  572 
diagnosis,  573 
pathology,  572 
symptoms,  573 
treatment,  583 
renal,  789 

and  appendicitis,  differ- 
entiation, 531 
composition,  790 
condition  of  opposite  kid- 
ney in,  793 
diagnosis,  795 

Rontgen  rays  in,  795 
wax-tipped  bougie  in, 
797 
etiology,  789 
pathology,  790 
pyelonephritis  associated 

with,  792 
symptoms,  793 
aseptic  cases,  793 
septic  cases,  794 
treatment,  797 
curative,  798 
prophylactic,  797 
Capillary  drainage  in  abdomi- 
nal and  pelvic  surgery,  715 
Capsule  of  kidney,  anatomy, 

749 
Carbolic  acid-poisoning,  post- 
operative, 70 
Carcinoma    cysts    of    breast, 
246 
of  body  of  stomach,  361 
of  breast,  222 

cachexia  as  sign,  188 
change  in  general  health 
as  sign,  188 
in    skin  and  subcuta- 
neous   fat    as    sign, 
186 
classification,  224 
diagnosis,  185 
duration  of  life,  253 
after  onset,  254 
after  operation,  253 
edema  as  sign,  187 
general     metastasis     as 

sign,  188 
Halsted's  operation,  259. 
See  also  Halsted's  op- 
eration   for    cancer    of 
breast. 


Carcinoma  of  breast,  import- 
ance of  complete  re- 
moval, 180,  181 
of  early  diagnosis,  180 
important    facts    to    be 
ascertained  in  history, 
189 
incomplete      operations, 

results,  255 
inoperable,   after   opera- 
tion, 254 
no  operation,  254 
internal  metastasis,  after 

operation,  254 
local     recurrence,    after 
complete       operation, 
253 
medullary,  233 
hemorrhagic,  236 
mixed  with  adenocar- 
cinoma -  comedo, 
234 
with    cystic    adeno- 
carcinoma, 235 
pure,  237 

resembling      sarcoma, 
237 
multiple  tumors  as  sign, 

188 
operable,  224 
operation,  complete,  259. 
See  also  Halsted's  op- 
eration   for    cancer    of 
breast. 
pain,  discharge  of  blood 
from  nipple,  and  fluc- 
tuation as  sign,  187 
palpation    of    tumor    in 

diagnosing,  185 
recurrent,     duration     of 
life     after     operation, 
255 
regionary       recurrences, 

after  operation,  254 
retraction    of    nipple    as 

sign,  186 
scirrhous,  240 
atrophic,  246 
circumscribed,  245 
skin  metastasis  as  sign, 

188 
ultimate  results  of  opera- 
-     tion,  224 
of  cardiac  orifice  of  stom- 
ach, 361 
gastrostomy  for,  365 
of    cervix    in    pregnancy, 

operation  for,  115 
of  hernial  contents,  666 
of  intestine,  427 
of  kidney,  805 
of  pancreas,  571 
diagnosis,  572 
symptoms,  571 
treatment,  592 
of  rectum,  474 

pregnancy,  operation  for, 

115 
metastases  in,  475 
treatment,  475 


INDEX. 


845 


Carcinoma  of  stomach,  351 
gastro  -  enterost  omy   for, 

328 
partial  gastrectomy  for, 

355 
pathologic  anatomy,  354 
pre-pyloric,  351,  352 
pyloric,  351 
symptoms,  352 
of  vermiform  appendix,  555 
treatment,  556 
Catarrhal  ulcer  of  intestine, 

422 
Catheter,  Jacobs',  300 
Catheterization  of  ureters  in 
operations     on     kidney, 
821 
Cauterization      in        hemor- 
rhoids, 511 
Van  Buren's,  in  prolapse  of 

rectum,  497 
zinc,  in  mahgnant  tumors 
of  rectum,  475 
Cells,  epithelial,  in  stomach, 
321 
pus,  in  stomach,  321 
Cervix,  amputation,  for  hy- 
pertrophy of  vaginal  por- 
tion,  in   pregnancy,   111 
cancer,  in  pregnancy,  oper- 
ation for,  115 
Cesarean  section,  79 

conditions      for      which 

done,  80 
Diihrssen's,  98 
history,  79 
incision,  90 

abdominal  route,  90 
instruments  required,  90 
Porro-,    98.         See    also 
Porro-Cesarean        sec- 
tion. 
post-mortem,  85,  86 
statistics,  97 
technic,  89 

time  for  operation,  89 
Chassaignac's    treatment    of 

hemorrhoids,  511 
Chemical    test    for    blood    in" 

stomach,  320,  322 
Cholangic     infections,     tem- 
perature angle  of,  285 
Cholecystectomy      for      gall- 
stones, 302 
history,  277 
Cholecystenterostomy         for 
gall-stones,  307 
history,  278 
Cholecystitis,  acute,  in  gall- 
stones, 286 
and     appendicitis,     differ- 
entiation, 531 
chronic,  in  gall-stones,  286 
in     pregnancy,     operation 
for,  108 
Cholecystostomy      for     gall- 
stones, 296 
Cholecystotomy      for      gall- 
stones. 296,  301 
history,  276,  277 


Choledochotomy,       drainage 
after,  723 
for  gall-stones,  306 
history,  278 

Cholelithotomy,  drainage 

after,  722 

Choleliths  as  cause  of  ileus, 
400 

Chondroma  of  rectum,  473 

Cicatricial   contraction  of  in- 
testine, 400 

Cigarette  drain,  714,  715 

Circumrenal      fistulse       post- 
operative, 50 

Clamp   and   cautery   method 
in  hemorrhoids,  512 

Cloaca,      primitive,      persis- 
tence, 470 

Coate's  method  of  ligation  in 
hemorrhoids,  510 

Coffey's    method    of    gastro- 
pexy,  373 
potato  bobbin,  433 

Coley's  operation  for  femoral 
hernia,  678 

Colic,  gall-stone,  282 

Colitis,  mucous,  and  chronic 
appendicitis,   relation,   530 

Colloid     adenocarcinoma     of 
breast,  227 

Colon,    idiopathic    dilatation 
of,  385 
treatment,  386 

Colopexy  in  prolapse  of  rec- 
tum, 503 

Colorectostomy,     sacral,     in 
stricture  of  rectum,  493 

Colostomy,  444 

Bodine's  method,  446 
Cripps'  method,  447 
iliac,  technic,  445 
inguinal,  technic,  445 
lumbar,  447 

Columns,  Bertini's,  752 

Common       bile-duct,       gall- 
stones in,  287 

Connell's  suture,  431 

Coronary    arteries    of    heart, 
embolism,  post- 

operative, 67 
thrombosis,    post-op- 
erative, 67 

Craniotomy,  80,  81 

Cripps'  method  of  colostomy, 
447 

Crises,    Dietl's,    in    movable 
kidney,  763 
tabetic,    and    ileus,    differ- 
entiation, 397 

Cryoscopy  of  blood  and  urine 
in  kidney  operations,   822 

Cushing's  operation  for  fem- 
oral hernia,  678 
suture,  431 

Cyclic  vomiting  in  children, 
acid  intoxication  in,  13 

Cystadenoma  of  breast,   200 

Cystic     adenocarcinoma     of 
breast,  229 
adenoma  of  breast,  220 


Cystic  disease  of  breast,  200 
ducts,   obstruction,   drain- 
age in,  724 
in  gall-stones,  285 
epithelioma,         intra-acin- 

ous,  of  breast,  200 

mastitis,  chronic,  200 

Cystitis,  post-operative,  43 

treatment,  45 
Cystonephrosis,  765 
Cysts,  cancer,  of  breast,  246 
dermoid,  of  breast,  214 
hydatid,  of  breast,  214 
of  kidney,  814 
of  liver,  311.     See    also 

Hydatids  of  liver. 
of  spleen,  612 
treatment,  612 
infected,  opening  into  rec- 
tum and  sigmoid,  465 
lymphatic,   of  breast,   248 
of  breast,  246 
of  glands  of  Montgomery, 

253 
of     kidney,     echinococcus, 
814 
simple  or  retention,  811 
of  ovary,  infected,  opening 

into  rectum,  465 
of  pancreas,  569 
classification,  569 
diagnosis,  570 
etiology,  569 
extirpation,  586 
incision     and     drainage, 

587 
pancreatotomia     gastro- 
colica  in,  589 
mesocolica  in,  590 
pathology,  569 
puncture,  586 
symptoms,  570 
treatment,  586 
of  rectum,  473 
of  spleen,  611 

treatment,  611 
of     vulva     in     pregnancy, 

operation  for,  115 
pararenal,  814 
pilonidal,  infected,  459 
post-rectal,  458 
sarcomatous,     of     breast, 

247 
with      intracystic      papil- 
lomatous 
growths,  of 

breast,  221 
discharge  of 

blood  from 

nipple  as  symp- 
tom, 222 
Czerny-Lembert   suture,   431 


Dawbarn's     potato     plates, 

434 
Decidua  in  tubal  pregnancy, 
144 
reflexa  in  tubal  pregnancy, 
146 


846 


INDEX. 


Decidua,   uterine,    in    tubal 

pregnancy,  149 
Decidual    formation    in    Fal- 
lopian tubes,  physical  and 
developmental     conditions 
which  favor,  136 
Decortication   of   kidney   for 
chronic     Bright 's     disease, 
830 
Decubital  ulcer  of  intestine, 

422 
Decubitus,        post-operative, 

11 
Delayed   shock   after   opera- 
tions, 1 
Dental    operations    in    preg- 
nancy, 116 
Depage's  method  of  gastros- 
tomy, 369 
Depression  of  nipple,  251 
Dermoid  cysts  of  breast,  214 
Dermoids  of  rectum,  473 
Diabetes  mellitus,  relation,  to 

pancreas,  561 
Diaphragmatic  hernia,  692 
Diarrhea    after   gastro-enter- 
ostomy,  343 
post-operative,  11 
Dietl's  crises  in  movable  kid- 
ney, 763 
Digital    di\'ulsion    for    hour- 
glass stomach,  349 
Dilatation,      idiopathic,      of 
colon,  385 
treatment,  386 
of      esophageal      stricture, 
gastrotomy  for  assisting 
in,  364 
of  stomach,  325 

acute,  post-operative,  33 
treatment,  34 
paradoxic,  as  symptom  of 
hour-glass  stomach,  346 
Dilators,  ureteral,  741 
Displaced  spleen,  404 

operations  for,  604 
Displacements    of    pancreas, 

575 
Diverticulum,     acc^uired,     of 
intestine,  387 
false,  of  intestine,  387 
from    lumen    of    tube    as 
cause     of     extrauterine 
pregnancy, 133 
ilei,  386 
Meckel's,  386 

inflammation      of,      and 
appendicitis,        difTer- 
entiation,  531 
of     vermiform     appendix, 
523 
Divulsion,   digital,   for  hour- 
glass stomach.  349 
Douches,   post-operative,    56 
Drain,  cigarette,  714,  715 
Drainage   after  choledochot- 
omy,  723 
after    cholelithotomy,    722 
after  vaginal   puncture   of 
pelvic  abscess,  720 


Drainage,  continued,  of  gall- 
bladder    in    gall-stones, 
302 
hepatic,  when  biliary  tract 

i§  infected,  723 
in    abdominal    and    pelvic 
surgery',  712 
capillary,  715 
distinction         from 

packing,  714 
general      considera- 
tions, 714 
history,  712 
materials  used,   714 
post-operative  care, 

730 
purpose.  714 
when  required,   716 
in   penetrating  wounds   of 

abdomen,  644 
in  peritonitis,  724 
.  of  appendical  abscess,  721 
of  bile-ducts,  722 
of  bladder,  730 
of  gall-bladder,  722 
of  gall-duct,  722 
of  hepatic  ducts.  723 
Kehr's  technic,  723 
Martin   and   Camett's 
technic,  724 
of  intestine,  730 
of  kidney,  729 
of  pancreas,  724 
of  pelvic  peritoneum,  718 
of  peritoneum.  724 
of  stomach,  724 
of  uterine  adnexa,  718 
of  uterus   718 
of  vermiform  appendix,  721 
post-operative  care,  730 
when    cystic    duct    is    ob- 
structed, 724 
when    gall-bladder    is    re- 
moved, 724 
Drainage-tube,     double,     for 
draining  cystic  or  common 
ducts,  307 
Drugs,    poisoning    by,    post- 
operative, 69 
Dtihrssen's      Cesarean      sec- 
tion, 98 
Duodenojejunal         junction, 
occlusion  at,  383 
region,  hernia,  692 
Duodenum,  ulcers,  419 
course.  421 
occlusion  of.  383 
ulcers,  round,  419 
symptoms,  421 
treatment,  422 
Dupuytren's  suture.  431 
Duret's    method    of    gastro- 

pexy.  371 
Dynamic  ileus,  397 
symptoms,  407 
treatment,  412 
Dysenteric  ulcer.  423 
Dysentery,  amebic,vermiform 

appendix  affected  in,  554 
Dystocia,  causes,  87 


Earl's        modification        of 
Whitehead's  operation  for 
hemorrhoids,  510 
Ectocolon,  385 
Ectopic  gestation,   130.    See 
also    Extrauterine    preg- 
nancy. 
products,   ruptured,   open- 
ing into  rectum  or  sig- 
moid, 465 
Ectropion  of  peritoneum,  pre- 
vention   of    post-operative 
intestinal  adhesions  by,  463 
Edebohls'   incision  in  opera- 
tions on  kidney,  817 
method  of  nephropexy,  824 
position   in   operations   on 
kidney,  817 
Edema,  local,  as  sign  of  can- 
cer of  breast,  187 
of  lungs,  post-operative.  41 
Elastic       strangulation       of 

hernia,  664 
Embolism,  arterial,  of  brain, 
post-operative.  67 
of    intestine,    post-oper- 
ative. 66 
of    spleen    and    kidney, 
post-operative.  68 
fat.  post-operative.  65 
intestinal  ulcers  from,  425 
of     coronary     arteries     of 
heart,  post-operative,  67 
of    mesenteric     artery    as 
cause  of  embolism,   394 
post-operative.  65 
pulmonary,      complicating 
appendicitis.  523 
post -operative.  39,  65 
treatment.  66 
venous,  of  intestine,  post- 
operative. 66 
of    spleen    and    kidney, 
post-operative.  68- 
Emphysema     of     abdominal 

walls,  post-operative.  55 
Empvema   of  kidney   pelvis, 

774 
Enchondroma  of  breast,  213 
Endocarditis,  post-operative, 

11 
End-to-side      intestinal      an- 
astomo.sis,  438 
with  Murphv  button, 
434,  435 
Enema,  post-operative.  55 
Enteroclysis.    continuous,    in 
after-treatment      of     peri- 
tonitis, 727 
Enterogenital  fistula.  454 
Entero-intestinal  fistula,  459 
Enteroliths  as  cau.se  of  ileus, 

400 
Enterorrhaphy    in    penetrat- 
ing   wounds    of    intestine, 
abstract  of  literature,  650 
Enterovaginal  fistula,  455 
abdominal      operations, 

456 
vaginal  operations.  456 


INDEX. 


847 


Enterovesical  fistula,  450 
treatment,  451,  455 
Epigastric  hernia,  685 
Epinephritis,  799.      See    also 

Paranephritis. 
Epithelial   cells   in   stomach, 
321 
tumors,  benign,  of  breast, 
220 
Epithelioma,       intra-acinous 

cystic,  of  breast,  200 
Eruptions,  post-operative,  69 
Erysipelas,  post-operative,  18 
Erythema,  post-operative,  69 
Esophagus,  foreign  bodies  in 
lower    end,    gastrotomy 
for,  363 
malignant  disease,  gastros- 
tomy for,  365 
scalding,   gastrostomy  for, 

366 
stricture,  gastrostomy  for, 
365 
gastrotomy  for  assisting 
in  dilatation,  364 
Excision  of  ulcers,  344 

partial,  of  spleen,  596 
Exclusion,  enteric,  442 
Extrauterine  pregnancy,  130 
adipocere  of  fetus  in,  160 
classification,  137 
conditions    which    inter- 
fere   with    downward 
passage  of  o\Tim,  131 
congenital  narrowing  of 
tubal  lumen  as  cause, 
134 
diagnosis,  165 
diseases  of  o\aim  in,  160 
diverticula    from    lumen 
of  tube  as  cause,   133 
effect    upon    subsequent 

child-bearing,  165 
etiology,  131 
external     migration     of 

ovum  as  cause,  135 
false  labor  in,  163,  164 
fate  of  fetus  in,  159 
frequency,  130 
laparotomy  in,  169 
litho-kelyphopedion     in, 

160 
litho-kelyphos  in,  160 
lithopedion  in,  159 
moles  in,  160 
mummification    of   fetus 

in,  159 
obstruction  by  twin  ova 

as  cause,  135 
pelvic  hematocele  in,  162 

treatment,  170 
peritoneal    adhesions    as 

cause,  131 
persistence  of  fetal  con- 
volutions of  Fallopian 
tube  as  cause,  135 
physical  and  develop- 
mental conditions 
which  favor  decidual 
formation  in  tubes,  136 


Extrauterine  pregnancy, 

puerperal  atrophy  of 
tube  as  cause,  135 

ruptured,  and  appendi- 
citis, differentiation, 
544 

salpingitis  as  cause,  131 

suppression  of  urine  in, 
161 

symptoms,  161 

treatment,  169 

tubal  polypi  as  cause, 
131 

tumors  of  tube  wall  as 
cause,  131 

varieties,  137 


Fallopian   tube,    congenital 
narrowing    of    lumen, 
as     cause     of     extra- 
uterine pregnancy, 134 
diverticula    from    lumen 
of,  as  cause  of  extra- 
uterine pregnancy, 133 
hernia  of,  659 
persistence  of  fetal  con- 
volutions, as  cause  of 
extrauterine  preg- 

nancy, 135 
physical     and     develop- 
mental conditions 
which   favor   decidual 
formation  in,  136 
polypi ,  as  cause  of  extra- 
uterine pregnancy, 131 
pregnancy  in,  141 
prolapse,  post-operative, 

78 
puerperal     atrophy,     as 
cause   of   extrauterine 
pregnancy,  135 
tumors,  as  cause  of  ex- 
trauterine   pregnancy, 
131 
False  diverticula  of  intestine, 
387 
labor  in  extrauterine  preg- 
nancy, 163,  164 
Fascia,  perinephric,  749 
Fat  embolism,  post-operative, 
65 
necrosis,  acute  pancreatic, 
and  ileus,    differentia- 
tion, 397 
of  pancreas,  562 
pathogenesis,  563 
surgical      significance, 
563 
Fecal        fistula,        artificial, 
Kocher's  method  of 
making,  443 
technic,  443 
impaction,  401 

treatment,  401 
strangulation  of  hernia,  664 
Feces,  incontinence,  after  op- 
eration for  fistula  in  ano, 
Robson's  method  of  repair, 
496 


Femoral  hernia,  675 
anatomy,  675 
Coley's  operation,  678 
Cushing's  operation,  678 
diagnosis,  676 
Noble's  operation,  679 
Ochsner's  operation,  677 
treatment,  677 
operation,  677 
vein,      thrombosis,      post- 
operative, 62,  63 
Ferguson's       operation      for 

inguinal  hernia,  708 
Fetal    convolutions   of   tube, 
persistence,   as  cause  of 
extrauterine    pregnancy, 
135 
kidney,  753 
Fetus,  adipocere  of,  in  extra- 
uterine pregnancy, 160 
fate     of,     in     extrauterine 

pregnancy,  159 
mummification,    in    extra- 
uterine pregnancy, 159 
Fever,  aseptic  wound,  15 
Fibroadenoma,      diffuse,      of 

breast,  200 
Fibro-epithelial     tumors     of 

breast,  214 
Fibroid  tumors  of  uterus  in 
pregnancy,    operation    for, 
109 
Fibroma  of  breast,  213 
of  intestine,  427 
of  kidney,  804 
of  rectum,  473 
of     vermiform     appendix, 
554 
Fibromyoma  of  intestine,  427 

of  rectum,  473 
Fibrosclerotic    paranephritis, 

799 
Finney's  method    of    pyloro- 
plasty, 375 
Gould's    modification, 
378 
Fistula    after    operation    for 
appendicitis,    treatment, 
542 
circumrenal,       post-opera- 
tive, 50 
enterogenital,  454 
entero-intestinal,  459 
entero vaginal,  455 
treatment,  455 

abdominal  operations. 

456 
vaginal         operations, 
456 
enterovesical,  450 
treatment,  451 

perineal  route,  453 
radical,  451 
fecal,     artificial,     Kocher's 
method   of  making, 
443 
technic,  443 
in  ano,  493 
dilatation,  495 
incision  with  closure,  495 


INDKX. 


Fistula  in  ano,  incontinence  of 
feces    after    operation 
for,   Robson's  metliod 
of  repair,  496 
injection,  495 
ligature,  497 
symptoms,  494 
thermocautery,  495 
treatment,  494 
operative,  494 
sequels,  495 
intestinal,  447 
nephro-enteric,  447 

treatment,  449 
pancreatic,  treatment,  594 
post-rectal,  458 

congenital,  458 

pyelo-enteric,  448 

treatment,  449 

rectovaginal,  456 

treatment,  457 

Bureau  and  Vignard's 

method,  457 
Fritsch's  method,  457 
renal,  post-operative,  50 
ureteral,  733 

congenital,  treatment  of, 

739 
post-operative,  51 
treatment,  738 
vaginal,      in      pregnancy, 

operation  for,  113 
vesical,  post-operative,   52 
Floating  kidney,   760.       See 

also  Kidney,  movable. 
Follicular  ulcer  of  intestine, 

422 
Foramen  of  Winslow,  hernia 

into,  693 
Forceps,  gall-stone,  298 
Foreign   bodies   as    cause   of 
ileus,  400 
symptoms,  410 
encysted,  in  breast,  214 
in  lower  end  of  esopha- 
gus,   gastrotomy    for, 
363 
in  stomach,  gastrotomy 

for,  361 
left    in    abdomen    after 
operation,  56 
in  wounds,  58 
Fowler's   position   in   diffuse 
septic  peritonitis,  728 
in    post-operative    peri- 
tonitis, 23 
Franck's  method  of  gastros- 
tomy, 366 
operation    in    wounds     of 
liver,  314 
Free  HCl  in  stomach,  test  for, 

320 
Fritsch's  method  of  treating 
rectovaginal  fistula,  457 


Galactocele,  196 

of  breast,  246 
Gall-bladder,  bacteria  in,  279 

bile  in,  279 


Gall-bladder, continued  drain- 
age, in  gall-stones,  302 

diseases,  etiology,  278 

drainage,  722 

operation,  Bevan's  incision, 
296 
Kocher's  incision,  296 
Robson's  incision,  296 
position,  295 

operations  on,  276 
history,  276 

removal,  drainage  in,  724 

trocar  for  aspirating,  297 
Gall-duct,  drainage,  722 

operation,     Bevan's     inci- 
sion, 296 
Kocher's  incision,  296 
Robson's  incision,  296 
position,  295 
Gall-stones,    acute    cholecys- 
titis in,  286 

age  and  sex  in  formation, 
280 

and     appendicitis,     differ- 
entiation, 531 

associated  with  acute  hem- 
orrhagic pancreatitis,  565 

bacteria  in,  279 

cholecystectomy  for,  302 

cholecystenterostomy    for, 
307 
after-treatment,  308 

cholecystostomy  for,  296 

cholecystotomv    for,     296, 
301 

choledochotomy  for,  306 

chronic     cholecystitis     in, 
286 

colic  in,  282 

continued  drainage  of  gall- 
bladder in,  302 

enlarged     gall-bladder    in, 
285 
liver  in,  285 

etiology,  278 

fever  in,  284 

forceps  for,  298 

ileus  from,  symptoms,   410 

in  common  bile-duct,   287 

incision  for  operations,  295 

jaundice  in,  283 

Murphy's  sign  in,  281 

obstruction  of  cystic  duct 
in,  285 

operation,  294 

contraindications,  291 
indications,  288 

pain  in,  281 

pathology,  288 

preparation  for  operation, 
294 
of  field  of  operation,  294 

spoon  for  removing,  298 

symptoms,  281 
special,  285 
stomach,  283 

temperature  in,  284 

treatment,  291 
Gangrene  of  lungs,  post-oper- 
ative, 41 


Gangrenous  pancreatitis,  566 

treatment,  578 
Gant's  operation  for  prolapse 

of  rectum,  500,  501 
Gastrectomy,  349 
complete,  349 
conditions   for  which  per- 
formed, 351 
definition,  349 
history,  349 
partial,  349,  355 

for   cancer   of   stomach, 
355 

for   hour-glass   stomach, 
349 
Gastro-anastomosis  for  hour- 
glass stomach,  349 
Gastro-enterostomy,  322 
anterior,  322,  336 
complications       following, 

339 
conditions   for  which  per- 
formed, 323 
definition,  322 
diarrhea  after,  343 
for    cancer     of     stomach, 

328 
for   congenital   stenosis   of 

pylorus,  327 
for     corrosion     of     gastric 

mucosa,  326 
for  ulcer  of  stomach,  323, 

326 
from     both     pouches     for 

hour-glass  stomach,  347 
from     cardiac     pouch    for 

hour-glass  stomach,  347 
hemorrhage  after,  340 
indications,  326 
inferior,  322 
intestinal  obstruction  after, 

341 
peptic    ulcer    of    jejunum 

after,  342 
posterior,  322,  329 

after-treatment  of,  335 

technic,  329 
preparation  of  patient,  329 
regurgitant  vomiting  after, 

340 
Roux's  method,  338 
Gastrogastrostomy  for  hour- 
glass stomach,  349 
Gastrojejunostomy,  322.    See 

also  Gastro-enterostomy. 
Gastro-mesenteric  ileus,  post- 
operative, 33 
Gastropexy,  370 

Beyea's  method,  371 
Coffey's  method,  373 
Buret's  method,  371 
Rovsing's  method,  374 
Gastroplasty    for    hour-glass 

stomach,  348 
Gastroptosis,  377 
multiparous,  370 
virginal,  370 
Gastrorrhaphy    in    penetrat- 
ing   wounds    of    stomach, 
abstract  of  literature,  650 


INDEX. 


849 


Gastrostomy,  365 
after-treatment,  369 
Albert  -  Franck  -  Kocher 

method,  366 
Albert-Franck's      method, 

366 
conditions  for  which  done, 

365 
Depage's  method,  369 
for    carcinoma    of    cardiac 

end  of  stomach,  365 
for    malignant    disease    of 

esophagus,  365 
for  scalding  of  esophagus 

or  stomach,  366 
for  stricture  of  esophagus, 

365 
Franck's  method,  366 
history,  365 
prognosis,  370 
Sbanajew-Franck's     meth- 
od, 366 
Senn's  method,  368 
Witzel's  method,  367 
Gastrotomy,  361 

for  assisting  in  dilatation  of 

esophageal  stricture,  364 

for  exploration  of  interior 

of  stomach,  363 
for  foreign  bodies  in  lower 
end    of    esophagus, 
363 
in  stomach,  361 
for    pedunculated    tumors 
of  stomach,  364 
Gaucher's  disease,  608 
Genital  organs,  female,  hernia 

of,  659 
Giuldjides'  method  of  treat- 
ing   tuberculosis    of    peri- 
toneum, 636 
Glenard's  disease,  370 
Glycosuria,     occurrence,     in 
association  with  pancreatic 
disease,  562 
Gonorrheal  salpingitis   open- 
ing into  rectum,  465 
Gould's  modification  of  Fin- 
ney's   method    of    pyloro- 
plasty, 378 
Grafting,  omental,    in    intes- 
tinal anastomosis, 
438,439 
technic,  438 
Granuloma,   infective,   of  in- 
testine, 425 
Gravidity     hypertrophy      of 

breast,  197 
Gridiron  incision  in  appendi- 
citis, 534 
Gumma  of  breast,  212 
Gunshot  wounds  of  kidney, 
754 
symptoms,  756 
treatment,  758  ' 
of    rectum,   abstract    of 

literature,  650 
of  spleen,  611 
Gynecologic  diseases,  appen- 
dicitis in  relation  to,  543 
VOL.  II — 54 


Gynecologic  operations,  com- 
plications following,  1.  See 
also  Operations. 


Halsted's  operation  for  can- 
cer of  breast,  259 
for  inguinal  hernia,  703 
suture,  431 
Hartmann's      button-holder, 

435 
HCl,   free,   in    stomach,  test 

for,  320 
Heart,  coronary  arteries,  em- 
bolism of,  post-oper- 
ative, 67 
thrombosis    of,    post- 
operative, 67 
Hematemesis,  post-operative, 

9 
Hematocele,  pelvic,  in  extra- 
uterine preg- 
nancy, 162 
treatment,  170 
periprocteal,  466 
retro-uterine,  466 
Hematoma  of  vulva  in  preg- 
nancy,  operation  for,    115 
Hemorrhage  after  gastro-en- 
terostomy,  340 
after  operations,  3 
symptoms,  4 
treatment,  6 
as  cause  of  ileus,  394 
from    bladder    or    kidney, 

post-operative,  48 
from   liver   in   penetrating 
wounds      of      abdomen, 
treatment,  643 
intestinal,   after   reduction 

of  hernia,  666 
renal,  of  unexplained  origin, 
815 
Hemorrhagic  medullary  car- 
cinoma of  breast,  236 
pancreatitis,     acute,     564. 
See      also      Pancreatitis, 
acute  hemorrhagic. 
Hemorrhoids,  504 

Allingham's  operation,  509 
American  operation,  512 
cauterization,  511 
Chassaignac's      treatment, 

511 
clamp  and  cautery  method, 

512 
Coates'  method  of  ligation, 

510 
excision  with  ligation,  509 
post-operative  infection, 505 
injection  treatment,  512 
ligation,  510 

Mathews'  method  of  liga- 
tion, 511 
Mitchell's  method  of  liga- 
tion, 510 
Ricketts'   method  of  liga- 
tion, 511 
sequels     after     operations 
for,  513 


Hemorrhoids,  treatment,  507 
Whitehead's  operation,  509 
Earl's       modification, 
510 
Hepatic  drainage  when  bili- 
ary tract  is  infected,  723 
ducts,  drainage,  723 

Kehr's  technic,  723 
Martin   and   Carnett's 
technic,  724 
Hepatotomy,  history,  277 
Hernia,  656 

accidents     and     complica- 
tions, 662 
appendicitis    complicating, 

665 
carcinoma  of,  666 
complications,  662 

after  operation  for,  666 

rare,  665 

treatment  of,  667 
contents,  658 
coverings,  658 
definition,  658 
diagnosis,  662 
diaphragmatic,  692 
epigastric,  685 
etiology,  661 
femoral,    675.         See   also 

Femoral  hernia. 
history,  656 

inflammation       complicat- 
ing, 662 

of  omentum  after  opera- 
tion for,  666 
inguinal,     670,     696.     See 

also  Inguinal  hernia. 
internal,  692 

treatment,  695 
intestinal  hemorrhage  after 

reduction,  666 
irreducibility,  663 

treatment,  667 
lumbar,  688 
obturator,  689 
of  bladder,  658 
of   duodenojejunal   region, 

692 
of  Fallopian  tubes,  659 
of   female   genital   organs, 

659 
of  foramen  of  Winslow,  693 
of  ileocecal  recess,  693 
of  intersigmoid  recess,  694 
of  linea  alba,  685 
of  ovary,  659,  660 
of  retrocecal  recess,  693 
of  retrovesical  recess,  694 
of  spleen,  611 
of  stomach,  661 
of  uterus,  659 
of  vermiform  appendix,  556 

treatment,  556 
perineal,  690 
pneumonia  after  operation 

for,  666 
post-operative,  686 

treatment,  687 
recurrence,  after  operation, 

666 


850 


INDEX. 


Hernia,  sciatic,  690 
strangulation,  399,  663 
diagnosis,  408 
elastic,  664 
fecal,  664 
symptoms    and    course, 

410,  664 
treatment,  668 
stricture    after    reduction, 

666 
treatment,    by    injections, 
667 
by  operation,  667 
by  truss,  666 
general,  666 
Treitz's,  692 

tuberculosis  of  sac  of,  666 
umbilical,  680 

Mayo's  operation,  680 
ventral,  684 
Hernies  tunicaires,  387 
Hilum  of  kidney,  anatomy, 

750 
Hirschsprung's  disease,  385 
Hodgkin's  disease,  616 
Horseshoe  kidney,  753 
Hour-glass  stomach,  345 

digital  divnlsion  for,  349 
gastro-anastomosis     for, 

349 
gastro-enterostomy  from 
both    pouches    for, 
347 
from     cardiac     pouch 
for,  347 
gastrogastrostomy      for, 

349 
gastroplasty  for,  348 
Kammerer's     operation, 

348 
Monprofit's       operation, 

348 
Moynihan's  sign,  346 
operative  treatment,  347 
partial  gastrectomy  for, 

349 
symptoms,  346 
von     Eiselsberg's     sign, 

346 
Weir  and  Foote's  opera- 
tion, 347 
Wolfler's  first  sign,   346 
second  sign,  346 
Hydatid  cysts  of  breast,  214 
of  kidney,  814 
of  liver,  311.     See  also 

Hydatids  of  liver. 
of  spleen,  612 
treatment,  612 
Hydatids  of  liver,  311 
diagnosis,  312 
etiology,  311 
symptoms,  311 
treatment,  312 
Hydronephrosis,  765 
acquired,  766 
congenital,  765 
diagnosis,  770 
pathologic  anatomy,  767 
post-operative,  49 


Hydronephrosis,      prognosis, 
770 
symptoms,  769 
treatment,    770 
Hydro-ureter,  post-operative, 

50 
Hyperdynamic  ileus,  397 
Hypernephroma    of    kidney, 

806 
Hypertrophy,     infantile,     of 
breast,  194 
lactation,    of   breast,    183, 
194 
and  tumors  of  breast, 
differentiation,  190 
malarial,  of  spleen,  607 

splenectomy  for,  607 
of  breast,  194 

diffuse  bilateral,  197 
in  pregnancy,  197 
in  virgin,  197 
senile     parenchymatous, 
200 
clinical     picture     of 
multiple 
tumors,     206 
of    one    tumor, 
203 
gross         pathology, 

207 
microscopic  pathol- 
ogy, 201 
treatment,  207 
of  spleen,  606 

in  infancy,  609 
of  vaginal  portion  of  cer- 
vix    uteri,     amputation 
for,  in  pregnancy,  111 
puberty,  of  breast,  182,194 
Hysterectomy   for   puerperal 
sepsis,  123 
indications,  127 
technic,  127 
Hysteria,  post-operative,   74 


Ileocecal  recess,  hernia,  693 
Ileum,  occlusion,  383 
Ileus,  390 

acute,  post-operative,  28 
adynamic,  391 
symptoms,  403 
treatment,  412 
after  extensive    operations 

on  mesentery,  392 
after     gastro-enterostomy, 

341 
after  return  of  strangulated 

bowel,  392 
and'   acute      hemorrhagic 
pancreatitis,        differ- 
entiation, 397 
pancreatic    fat    necrosis, 
differentiation,  397 
and   tabetic   crises,   differ- 
entiation, 397 
choleliths  as  cause,  400 
chronic,  post-operative,  29 
clinical  course,  402 
diagnosis,  402 


Ileus,  dynamic,  397 
symptoms,  407 
treatment,  412 

embolism  of  mesenteric 
artery  as  cause,  394 

enteroliths  as  cause,  400 

etiology,  402 

foreign  bodies  as  cause,  400 

from  foreign  bodies,  symp- 
toms, 410 

gall-stones  as  cause,  symp- 
toms, 410 

gastro-mesenteric,  post- 
operative, 33 

hemorrhage  as  cause,  394 

history,  402 

hyperdynamic,  397 

infection,  396 
symptoms,  405 

injury    of    afferent    nerve- 
supply  as  cause,  394 
of  spinal  cord  as  cause, 
394 

mechanical,  398 
symptoms,  407 
treatment,  412 

obturator,  399 

paralytic,  391 

post-operative,  32 

pathologic  lesions  as  cause, 
394 

pathology,  391 

post-operative,  25,  415 
adhesions  as  cause,  26 
causes,  26 
diagnosis,  29,  416 
prognosis,  30 
treatment,  30,  417 
operative,  418 

proctoclysis  in,  414 

reflex,  394 

symptoms,  404 

septic,  396 

symptoms,  405 

spastic,  post-operative,   32 
treatment,  33 

symptoms,  403 

towel  method  of  replacing 
bowels  after  operation 
for,  413 

treatment,  411 

tumors  as  cause,  399 

uremic,  396 
symptoms,  407 
Iliac  colostomy,  technic,  445 
Imperforate  anus,  469,  470 
Incision,  abdominal,  in  Ces- 
arean section,  90 
separation  of,  post-oper- 
ative, 53 
treatment,  54 

Brodel's,  in  nephrotomy, 
832 

Edebohls',  in  operations  on 
kidney, 817 

for  removal  of  appendix  in 
pelvic  diseases  compli- 
cating appendicitis,   545 

gridiron,  in  appendicitis, 
534 


INDEX. 


851 


Incision  in  Cesarean  section, 
90 

abdominal  route,  90 
into  paranephric  area,  823 
Israel's,  in    operations    on 

kidney,  820 
Kelly's,    in    operations    on 

kidney,  818 
Langenbuch's,    for    opera- 
tions on  kidney,  820 
lateral,    in   pelvic   diseases 
complicating       appendi- 
citis, 546 
McBurney's,    in    appendi- 
citis, 534 
median,     in     appendicitis, 

534 
-Morris' ,   for   nephrectomy, 
820 
for  nephrolithotomy,  819 
Robson's,  in  operations  on 

kidney, 818 
semilunar,  in  appendicitis, 

534 
transperitoneal,    in    opera- 
tions on  kidney,  820 
Incontinence    of    feces    after 
operation  for  fistula  in 
ano,    Robson's    method 
of  repair,  496 
of     urine,     post-operative, 
43 
Indigo-carmin  test  in  kidney 

operations,  821 
Induction  of  premature  labor, 

80,  81,  82 
Infantile     breast,     anatomic 
and   histologic   remarks, 
182 
hypertrophy  of  breast,  194 
Infection  ileus,  396 
symptoms.  405 
local,    due    to   pathogenic 
bacteria,  post-operative, 
15 
of  nipple,  251 

portal,     complicating     ap- 
pendicitis, 523 
post-operative,  15 
in  hemorrhoids,  505 
Infective  granuloma  of  intes- 
tine, 425 
Inflammation      complicating 
hernia,  662 
of    Meckel's    diverticulum 
and  appendicitis,  differ- 
entiation, 531 
of  omentum  after  operation 

for  hernia.  666 
of  paranephric  tissues,  799 
pelvic,  in  pregnancy,  oper- 
ation for,  115 
Inflammatory      diseases      of 
right  adnexa  uteri  and 
appendicitis,    differen- 
tiation, 544 
of  vermiform  appendix, 
550 
lesions,      non-tuberculous, 
of  kidney,  774 


Inguinal  colostomy,  technic, 
445 
hernia,  670,  696 

Bartlett's  treatment,  711 
Bassini's  operation,  710 
Bloodgood's     operation, 

707 
complete,  697 
conditions    predisposing, 

699 
definition,  696 
diagnosis,  671 
direct.  697 
external,  697 
Ferguson's        operation, 

708 
Halsted's  operation,  703 
incomplete,  697 
internal,  697 
local    anesthesia    in  op- 
erations for,  673 
obhque,  697 
operations,  696 
history,  696 
symptoms,  698 
treatment,  672 
operative,  699 
anesthesia,  700 
preparations,  700 
technic,  702 
varieties,  697 
Insanity   from   poisoning  by 
drugs,  post-operative,  69 
post-operative   76 
treatment,  77 
Instruments  for  Porro-Cesar- 
ean  section,  102 
required   in   Cesarean   sec- 
tion, 90 
Interlobular  stroma  of  breast, 

182 
Internal  hernia,  692 
treatment,  695 
Intersigmoid    recess,    hernia, 

694 
Interstitial  pancreatitis, 

chronic.     568.       See     also 
Pancreatitis,     chronic     in- 
terstitial. 
Intestinal  adhesions  as  cause 
of    post-operative    in- 
testinal     obstruction, 
26 
post-operative,  460 
cauterization  as  cause, 

460 
etiology,  460 
of  omentum,  461 
of  rectum,  462 
of  sigmoid,  462 
of  small  intestine,  462 
of  urinary  organs,  462 
pathology,  461 
prophylaxis,  462 

by  covering  abraded 

surfaces,  462 
by  distention  of  ab- 
dominal cavity  by 
artificial     means, 
464 


Intestinal  adhesions,  post-op- 
erative,  prophyl- 
axis by  ectropion 
of  peritoneum ,  463 
by  fold  of  loose  peri- 
toneum  to   cover 
abraded  surfaces, 
462 
by      involution      of 
abraded  surfaces, 
462 
by   peritoneoplasty, 

463 
by  position,  463 
separation,  464 
symptoms,  461 
separation   of,   from   in- 
fected cysts  or  malig- 
nant tumors,  389 
anastomosis,  433 

by  sutures  and  mechani- 
cal aids,  433 
end-to-end,  438 

with  Murphy  button, 
434,  435 
in  fixed  zones,  441 
omental      grafting      in, 
Senn's      method, 
439 
technic,  438 
side-to-side,  439 
fistula,  447 

hemorrhage     after    reduc- 
tion of  hernia,  666 
obstruction,  390.     See  also 

Ileus. 
sutures,  430 
Intestine,     abnormal    termi- 
nations, 468 
acquired  diverticulum, 

387 
actinomycosis,  425 

treatment,  426 
adenoma,  427 
angioma,  427 
anthrax,  424 

arterial     embolism,     post- 
operative, 66 
thrombosis,      post-oper- 
ative, 66 
carcinoma.  427 
catarrhal  ulcer,  422 
choleliths   in,   as   cause   of 

ileus,  400 
cicatricial  contraction,  400 
decubital  ulcer,  422 
drainage,  730 
enteroliths  in,  as  cause  of 

ileus,  400 
exclusion,  442 
bilateral,  442 
complete,  442 
partial,  442 
unilateral.  442 
false  diverticulum,  387 
fecal  impaction  in,  401 

treatment,  401 
fibroma,  427 
fibromyoma,  427 
follicular  ulcer,  422 


852 


INDEX. 


Intestine,  foreign  bodies  in, 
as  cause  of  ileus, 
400 
symptoms,  410 
infective  granuloma,  425 
injuries   to,   during  opera- 
tions, 389 
large,  penetrating  wounds, 
abstract     of     literature, 
650 
lipoma,  427 
malformations,  383 
myoma,  427 
occlusion,  383 
penetrating    wounds,     ab- 
stract  of  literature, 
649 
enterorrhaphy  in,  ab- 
stract of  literature, 
650 
peptic  ulcer,  419 
repair,  429 
sarcoma,  428 
stercoral  ulcer,  422 
surgery,  383 
syphilis,  427 
torsion,  399 
toxic  ulcers,  425 
tuberculous  ulcer,  423 

symptoms,  425 
tumors,  427 

as  cause  of  ileus,  399 
benign,  427 
malignant,  427 
ulcers,  419 

from  anthrax,  424 

from  burns,  424 

from       embolism       and 

thrombosis,  425 
from  uremia,  425 
venous     embolism,      post- 
operative, 66 
thrombosis,      post-oper- 
ative, 66 
Intoxication,   acid,   in   cyclic 
vomiting   in   children, 
13 
post-operative,  13 
Intralobular  stroma       of 

breast,  182 
Intraperitoneal    abscess,    ab- 
dominal      section      for, 
121 
operations      in      infection 
technic,  718 
Intussusception,  399 
post-operative,  27 
symptoms,  409 
Invagination,  399 
symptoms,  409 
Involution,      abnormal,      of 

breast,  200 
lodoform-poisoning,        post- 
operative, 70 
Irreducibility  of  hernia,  663 

treatment,  667 
Irrigations,      post-operative, 

56 
Isoperistaltic       anastomosis, 
322 


Israel's  incision  in  operations 
on  kidney,  820 
operation  of  pyeloplication, 
773 


Jacob's  retention  catheter, 
300 

Jaundice  in  gall-stones,   283 

Jeannel's  operation  for  pro- 
lapse of  rectum,  503 

Jejunum,  peptic  ulcer  of, 
after  gastro-enterostomy, 
342 


Kammerer's    operation    for 

hour-glass  stomach,  348 
Kehr's   method    of    draining 

hepatic  duct,  723 
Kelly's  incision  in  operations 

on  kidney,  818 
Kidney,   abnormalities,    con- 
genital, 753 
form,  753 
number,  753 
position,  753 
abscess,  774 
absence,  753 
adenocystoma,  814 
adenoma,  804 
anatomy,  748 
arterial     embolism,     post- 
operative, 68 
thrombosis,      post-oper- 
ative, 68 
blood-clots    in,    post-oper- 
ative, 48 
cake,  753 
calculus,  789.         See    also 

Calculus,  renal. 
capsule,  anatomy,  749 
carcinoma,   805 
cysts,  echinococcus,  814 

simple  or  retention,  811 
decortication,    for    chronic 

Bright's  disease,  830 
diseases,  post-operative,  45 

surgical  treatment,  816 
drainage,  729 
embryology,  748 
embryonic  sarcoma,  805 
fetal,  753 
fibroma,  804 
fistula,   post-operative,    50 

treatment,  51 
floating,      760.       See  also 

Kidney,  movable. 
hemorrhage  from,  of  unex- 
plained origin,  815 
post -operative,  48 
hilum  of,  anatomy,  750 
horseshoe,  753 
hypernephroma,  806 
inflammatory  lesions,  non- 
tuberculous,  774 
injuries,      754.       See  also 

Wounds  of  kidney. 
lipoma,  805 
lumpy,  753 


Kidney,  movable,  760 

and     appendicitis,     dif- 
ferentiation, 531 
diagnosis,  763 
Dietl's  crises  in,  763 
etiology,  760 
frequency,  760 
pathology,  762 
symptoms,  762 
treatment,         non-oper- 
ative, 765 
operative,  indications, 
764 
neuralgia,  814 
operations  on,  816 

cryoscopy  of  blood  and 

urine  in,  822 
determination  of  amount 
of  urea  in,  821 
of    renal    function  in, 
821 
Edebohls'    incision,    817 

position,  817 
general    remarks,    816 
incision  for  exposing  kid- 
ney, 817  _ 
indigo-carmin     test     in, 

821 
Israel's  incision,  820 
Kelly's  incision,  818 
Langenbuch's      incision, 

820 
phloridzin  test  in,  822 
position  of  patient,  817 
post-operative         treat- 
ment, 817 
Robson's  incision,  818 
transperitoneal   incision, 

820 
ureteral     catheterization 
in,  821 
pelvis,  empyema,  774 

tumors,  810 
physiology,  753 
polycystic  disease,  812 

treatment,  814 
position,  748 
relations,  750 
rudimentary,  753 
rupture,  755 

treatment,  758 
sacculated,  782 
•  treatment,  782 
sarcoma,  805 
shield-shaped,  753 
stone,  789.     See  also  Cal- 
culus, renal. 
subparietal  injury,  755 

treatment,  758 
supernumerary,  753 
surgery,  747 

history,  747 
tuberculosis,  783.     See  also 

Tuberculosis  of  kidney. 
tumors,      803.       See  also 

Tumors  of  kidney. 
unilateral  long,  753 
vascular   supply,    relation, 
to     kidney     pelvis     and 
calyces,  750 


INDEX. 


853 


Kidney,    venous     embolism, 
post-operative,  68 
thrombosis,      post-oper- 
ative, 68 
wounds,    754.         See    also 
Wounds  of  kidney. 
Kocher's    incision    for    gall- 
bladder    and     gall-duct 
operation,  296 
method  of  making  artificial 
fecal  fistula,  443 
Kousnietzoff's      needles      for 

suturing  liver,  314 
Kraske's    operation    for   ma- 
lignant tumors  of  rectum, 
479 
Kiister's  sac-kidney,  765 


Labor,      appendicitis      com- 
plicating, 548 
false,  in  extrauterine  preg- 
nancy, 163,  164 
premature    induction,    80, 
81,  82 
Lactation     hypertrophy      of 
breast,  183,  194 
and  tumors  of  breast, 
differentiation,     190 
mastitis,  209 

and    tumors    of    breast, 

differentiation,  190 
diagnosis,  210 
treatment,  210 
Lactic  acid  in  stomach,  320 
Langenbuch's      incision     for 
operations  on  kidney,  820 
Lang's  operation  for  prolapse 

of  rectum,  497 
Laparotomy.       See  Abdomi- 
nal section. 
Lembert's  suture,  430 
Leukemia,  lymphatic,  616 
splenic,  615 

splenectomy  in,  616 
Leukocytosis    as     diagnostic 
and     prognostic     sign     in 
appendicitis,  529 
Ligament,     broad,      rupture 
into,   in   tubal   pregnancy, 
156 
Ligation  in  hemorrhoids,  510 
Coates'  method,  510 
Mathews'  method,  511 
Mitchell's  method,  510 
Ricketts'  method,  511 
of  one  of  splenic   vessels, 
596 
Linea  alba,  hernia,  685 
Lipoma  of  breast,  213 
of  intestine,  427 
of  kidney,  805 
of  rectum,  473 
of     vermiform     appendix, 
554 
Lipomatous       paranephritis, 

800 
Lithiasis.     See  Calculus. 
Litho-kelyphopedion    in    ex- 
trauterine  pregnancy,    160 


Litho-kelyphos  in  extrauter- 
ine pregnancy, 160 
Lithopedion    in   extrauterine 

pregnancy,  159 
Liver,  abscess,  309.     See  also 
Abscess  of  liver. 
diseases,  309 
enlargement,  in  gall-stones, 

285 
hemorrhage  from,  in  pene- 
trating   wounds    of    ab- 
domen, 643 
hydatids,   311.        See  also 

Hydatids  of  liver. 
operations  on,  276 

history,  276 
wounds,  312 

Franck's  operation,  314 
treatment,  312 
Lobar       pneumonia,       post- 
operative, 37 
Lumbar  colostomy,  447 

hernia,  688 
Lumpy  kidney,  753 
Lungs,     abscess,     post-oper- 
ative, 41 
edema,   post-operative,   41 
embolism,     post-operative, 
39,  65 
treatment,  66 
gangrene,     post-operative, 

41 
post-operative       complica- 
tions involving,  35 
tuberculosis,         post-oper- 
ative, 41 
Lymphatic    cysts    of   breast, 
248 
leukemia,  616 


Malaria,  post-operative,  71 
Malarial       hypertrophy       of 
spleen,  607 
splenectomy  for,  607 
Malignant  disease  of  esopha- 
gus,  gastrostomy   for, 
365 
of  ureter,  733 
treatment,  745 
papilloma  of  renal  pelvis, 

810 
tumors  in  pregnancy,  oper- 
ation for,  115 
of  areola,  253 
of  breast,  diagnosis,  185 
pain,      discharge      of 
blood    from    nipple, 
and    fluctuation    in 
diagnosing,  187 
of  intestine,  427 
of  kidney,  805 
of  rectum,  474 

abdomino    -    perineal 

operation,  486 
general  treatment,  475 
Kraske's       operation, 

479 
Quenu's    perineal    op- 
eration, 477 


Malignant  tumors  of  rectum, 
radical      treatment, 
475 
Rehn-Rydygier    oper- 
ation, 480 
vaginal  extirpation  of 

rectum,  481 
zinc   cauterization   in, 
475 
Martin  and  Carnett's  method 
of    draining    common    and 
hepatic  ducts,  724 
Mastitis,  208 

cystic,  chronic,  200 
lactation,  209 

and    tumors    of    breast, 

differentiation,  190 
diagnosis,  210 
treatment,  210 
of     non-lactating     breast, 

211 
pyogenic,  208 
syphilitic,  212 
tubercular,  211 
Mastodynia,  193 
Mathews'  method  of  ligation 

in  hemorrhoids,  511 
Mayo's    method    of   treating 
tuberculosis     of     perito- 
neum, 635 
operation      for      umbilical 
hernia,  684 
McBurney's    incision    in   ap- 
pendicitis, 534 
Mechanical  ileus,  398 
symptoms,  407 
treatment,  412 
Meckel's  diverticulum,  386 
inflammation  of,  and  ap- 
pendicitis, differentia- 
tion, 531 
Median  incision  in  appendi- 
citis, 534 
Megacolon,  385 
Menstruation,       suppression, 
in  extrauterine  pregnancy, 
161 
Mental     impression,    advisa- 
bility    of     operating     for 
effect,  77 
Mercury-poisoning,  post- 

operative, 70 
Mesenteric  artery,  embolism, 

ileus  from,  394 
Mesentery,   extensive   opera- 
tions on,  ileus  after,  392 
Metastasis,    general,  as    sign 
of  cancer  of  breast,  188 
skin,  as  sign  of  cancer  of 
breast,  188 
Metastatic  sarcoma  of  breast, 

251 
Mikulicz's  operation  for  pro- 
lapse of  rectum,  499 
Miliary    tuberculosis,    acute, 

of  peritoneum,  623 
Mitchell's  method  of  ligation 

in  hemorrhoids,  510 
Moles   in   extrauterine   preg- 
nancy, 160 


854 


INDEX. 


Monprofit's      operation      for 
'    hour-glass  stomach,  348 
Montgomery's  glands,  cysts, 
'    253 

Morris'  incision  for  nephrec- 
tomy, 820 
for  nephrolithotomy,  819 
Movable    kidney,    760.     See 

also  Kidney,  movable. 
Moynihan's     sign     in     hour- 
glass stomach,  346 
Mucous    colitis    and    chronic 
appendicitis,   relation,   530 
Multiparous  gastroptosis, 

370 
Mummification  of  fetus  in  ex- 
trauterine  pregnancy,   159 
Murphy     button,     intestinal 
anastomosis  with,  434,  435 
Murphy's  oblong  button,  437 
operation   for   prolapse   of 

rectum,  503 
sign  in  gall-stones,  281 
telescoping      proctoscopes, 

467 
treatment  of  acute  general 
post-operative        perito-- 
nitis,  23 
Myoma  of  intestine,  427 
of  rectum,  473 
of     vermiform     appendix, 
554 
Myxoma,  intracanalicular,  of 
breast,  214 

recurrent,  217 
spontaneous        disap- 
pearance, 217 
sarcoma  of  breast  in,  249 
of     vermiform     appendix, 
554 


Necrosis,    fat,    acute    pan- 
creatic, and  ileus,  dif- 
ferentiation, 397 
of  pancreas,  562 
pathogenesis,  563 
surgical      significance, 
563 
Needles,    Kousnietzoff's,    for 

suturing  liver,  314 
Neff's     method     of    treating 
tuberculosis       of       perito- 
neum, 636 
Nephrectomy,  836 
abdominal,  838 
history,  747 
Morris'  incision,  820 
partial,  839 
subcapsular,  836 
Nephritis,    acute,    post-oper- 
ative, 46 
Nephro-enteric  fistula,  447 

treatment,  449 
Nephrolithiasis,   789.  See 

also  Calculus,  renal. 
Nephrolithotomy,  834 

Morris'  incision  for,  819 
Nephropexy,  824 

Brodel's  suture  in,  827 


Nephropexy ,  Edebohls' 

method,  824 
Noble's  method,  828 
Penrose        and        Beyea's 

method,  828 
Senn's  method,  828 
Nephroptosis,  760.      See  also 

Kidney,  movable. 
Nephrotomy,  831 

Brodel's  incision  in,  852 
history,  748 
Nephrotriesis,  833 
Nephro-ureterectomy,  839 
in   tuberculosis    of   ureter, 
744 
Nerve-supply,  afferent,  injury 

to,  ileus  from,  410 
Neuralgia  of  breast,  193 

renal,  814 
Neurasthenia,  post-operative, 
74 
treatment,  75 
Nipple,  absence,  251 
adenoma,  253 
depression,  251 
disease,  251 
infection,  251 
Paget's  disease,  252 
papilloma,  253 
retraction,  as  sign  of  can- 
cer of  breast,  186 
syphilitic  lesions,  253 
Noble's    method    of   nephro- 
pexy, 828 
operation       for       femoral 
hernia,  679 


Obstruction,  intestinal, 

post-operative,    25.        See 
also  Intestinal  obstruction. 
Obturator  hernia,  689 

ileus,  399 
Occlusion  at  duodenojejunal 
junction,  383 
of  duodenum,  383 
of  ileum,  383 
of  intestine,  383 
Ochsner's  method  of  treating 
tuberculosis     of     perito- 
neum, 636 
operation       for       femoral 
hernia,  677 
Omental  grafting  in  intesti- 
nal    anastomosis,  Senn's 
method,  439 
technic,  438 
Omentum,  inflammation, 

after -operation  for  hernia, 
666 
post-operative     adhesions, 

461 
torsion,  394 
diagnosis,  396 
pathologic  anatomy,  395 
symptoms,  410 
treatment,  396 
Operations,  abscess  of  lungs 
after,  41 
acetonuria  after,  13 


Operations,  acid  intoxication 
after,  13 
aciduria  after,  13 
acute   dilatation   of   stom- 
ach after,  33 
treatment,  34 
intestinal        obstruction 
after,  28 
arterial  embolism  of  brain 
after,  67 
of  intestine  after,  66 
of  spleen  and  kidney 
after,  68 
rupture  of  brain  after,  67 
thrombosis  after,  61 
of  intestine  after,  66 
of  spleen  and  kidney 
after,  68 
atropin-poisoning  after,  69 
bed-sores  after,  11 
blood-clots  in  bladder  and 

kidney  after,  48 
brachycardia  after,  11 
bronchitis  after,  42 
bronchopneumonia      after, 

37 
burns  after,  53 
carbolic  acid-poisoning 

after,  70 
chronic  intestinal  obstruc- 
tion after,  29 
circumrenal  fistulse  after,  50 
complications  after,  1 
cystitis  after,  43 
treatment,  45 
decubitus  after,  11 
delayed  shock  after,  1 
diarrhea  after,  11 
diseases  of  bladder  after,  42 
of  bronchi  after,  35 
of  kidneys  after,  45 
of  lungs  after,  35 
douches  after,  56 
during  pregnancy,  106 

management,  116 
dynamic  ileus  after,  32 
embolism  after,  65 

of    coronary   arteries   of 
heart  after,  67 
emphysema   of  abdominal 

walls  after,  55 
endocarditis  after,  11 
enema  after,  55 
eruptions  after,  69 
erysipelas  after,  18 
erythema  after,  69 
fat  embolism  after,  65 
foreign  bodies  left   in  ab- 
domen after,  56 
left  in  wounds  after,  58 
gangrene  of  lungs  after,  41 
gastro-mesenteric  ileus 

after,  33 
hematemesis  after,  9 
hemorrhage  after,  3 

from    bladder   and    kid- 
ney after,  48 
symptoms,  4 
treatment,  6 
hydronephrosis  after,  49 


INDEX. 


855 


Operations,  hydro-ureter 

after,  50 
hysteria  after,  74 
incontinence  of  urine  after, 

43 
infections  after,  15 
insanity  after,  76 

from  poisoning  by  drugs 

after,  69 
treatment,  77 
intestinal  obstruction  after, 
25 
adhesions  as  cause,  26 
causes,  26 
diagnosis,  29 
prognosis,  30 
treatment,  30 
intussusception  after,  27 
iodof  orm-poisoning  after,  70 
irrigations  after,  56 
late    poisonous    effects    of 

anesthetics,  14 
lobar  pneumonia  after,  37 
local     infections     due     to 
pathogenic  bacteria 

after,  15 
malaria  after,  71 
mercury-poisoning  after,  70 
nephritis  after,  46 
neurasthenia  after,  74 

treatment,  75 
non-septic  pneumonia 

after,  37 
ophthalmia  after,  12 
opium-poisoning   after,    69 
paralytic  ileus  after,  32 
parametritis  after,  16 
parotitis  after,  12 

treatment,  13 
peculiarities  of  pulse  after, 

10 
pericarditis  after,  11 
peritonitis    after,    general, 
acute,     19.     See    also 
Peritonitis,     post-oper- 
ative, general,  acute. 
local,  18 

treatment,  19 
pleurisy  after,  40 
pneumonia  after,  37 

treatment,  38 
poisoning  by   drugs   after, 

69 
pressure  paralysis  after,  52 
prolapse  of  Fallopian  tube 

after,  78 
pulmonary  edema  after,  41 
embolism  after,  39,  65 

treatment,  66 
tuberculosis  after,  41 
purpuric  rashes  after,  69 
pyelitis  after,  48 
pyemia  after,  23,  24 

treatment,  25 
pyonephrosis  after,  48 
pyuria  after,  49 
renal  fistula;  after,  50 
retention  of  urine  after,  42, 
46 
treatment,  48 


Operations,    sapremia   after, 
17 
separation     of     abdominal 
incision   after,  53 
treatment,  54 
septicemia  after,  23,  24 

treatment,  24 
shock  after,  1 

treatment,  2 
sloughing     of     abdominal 

wall  after,  55 
spastic  ileus  after,  32 
treatment,  33 
strychnin-poisoning    after, 

69 
syphilis  after,  73 
syphilitic  fever  after,  73 
tachycardia  after,  10 
thrombosis  after,  59 

of   coronary    arteries    of 

heart  after,  67 
of  femoral  vein  after,  62, 

63 
of     pelvic     veins     after, 

63 
of     portal     vein     after, 

68 

prognosis,  64 

symptoms,  63 

.treatment,  64 

tympanites  after,  9 

treatment,  10 
typhoid  fever  after,  71 
ureteral  fistula  after,  51 
urticaria  after,  69 
venous  embolism  of  intes- 
tine after,  66 
of  spleen   and  kidney 
after,  68 
thrombosis  after,  61 
of  intestine  after,  66 
of  spleen   and  kidney 
after,  68 
vesical  fistute  after,  52 
volvulus  after,  27 
vomiting  after,  7 
treatment,  8 
Ophthalmia,    post-operative, 

12 
Opium-poisoning,    post-oper- 
ative, 69 
Osteoma  of  breast,  213 

of  rectum,  473 
Ovarian  cysts,  infected,  open- 
ing into  rectum,  465 
hernia,  659,  660 
pregnancy, 137 
tumor  with  twisted  pedicle 
and     appendicitis,     dif- 
ferentiation, 544 
Ovum,    diseases,    in    extra- 
uterine pregnancy, 160 
external       migration,       as 
cause      of     extrauterine 
pregnancy, 135 
mode   of   implantation,   in 

tubal  pregnancy,  142 
twin,    obstruction    by,    as 
cause     of     extrauterine 
pregnancy,  135 


Paget's  disease  of  nipple,  252 
Pancreas,  abscess,  567 
treatment,  580 
adenoma,  591 

treatment,  591 
carcinoma,  571 
diagnosis,  572 
symptoms,  571 
treatment,  592 
cysts,  569.     See  also  Cysts 

of  pancreas. 
diseases,  occurrence  of  gly- 
cosuria  in  association 
with,  562 
surgical   treatment,    573 
historical,  573 
displacements,  575 
drainage,  724 

exposure,  localities  for,  559 
fat  necrosis,  562 

pathogenesis,  563 
surgical      significance, 
563 
fistula,  treatment,  594 
injuries,  576 
diagnosis,  576 
in  penetrating     wounds 
of     abdomen,-     treat- 
ment, 643 
treatment,  577 
pathology,  general,  560 
preservation   of   tissue,    in 

operation,  562 
prolapse,  575 

treatment,  575 
ranula,  569 

sarcoma,  treatment,  592 
relation  of  diabetes  melli- 

tus  to,  561 
surgery,  557 

history,  557 
surgical  anatomy,  558 

topography,  574 
syphihs,  591 

treatment,  591 
tuberculosis,  591 
treatment,  591 
tumors,  treatment,  591 
wounds,  576 
diagnosis,  576 
treatment,  577 
Pancreatic  apoplexy,  564 
treatment,  580 
calculus,     572.     See     also 

Calculus,  pancreatic. 
fat    necrosis,    acute,    and 
ileus,  differentiation,  397 
fistula,  treatment,  594 
juice,   escape,   into   perito- 
neum, 561 
Pancreatitis,     acute     hemor- 
rhagic, 564 
diagnosis,  566 
etiology,  564 
treatment,  578 
chronic  interstitial,  588 
etiology,  568 
pathology,  568 
treatment,  581 
gangrenous,  566 


856 


INDEX. 


Pancreatitis,    gangrenous, 
treatment,  578 
suppurative,  567 
symptoms,  567 
treatment,  580 
Pancreatotomia    gastrocolica 
in  pancreatic  cysts,  589 
mesocolica     in     pancreatic 
cysts,  590 
Papilloma,      malignant,      of 
renal  pelvis,  810 
of  nipple,  253 
of  rectum,  473 
Paradoxic  dilatation  as  symp- 
tom of  hour-glass  stomach, 
346 
Paralysis,      pressure,      post- 
operative, 52 
Paralytic  ileus,  391 

post-operative,  32 
Parametritis,  post-operative, 

16 
Paranephric     area,     incision 
into,  823 
tissues,  inflammation,  799 
Paranephritis,  799 
diagnosis,  802 
fibrosclerotic,  799 
lipomatous,  800 
pathologic  anatomy,  800 
phlegmonous,  800 
prognosis,  803 
symptoms,  801 
treatment,  803 
Pararenal  cysts,  814 

tumors,  811 
Parenchyma  of  breast,  182 
Parotitis,  post-operative,  12 

treatment,  13 
Pedicle,  twisted,  in  wander- 
ing spleen,  605 
Pelvic   abscess   opening  into 
rectum,  465 
vaginal  puncture,  drain- 
age after,  720 
affections    in    female    and 
appendicitis,    dif- 
ferentiation,   530, 
544 
incision  for  removal 
of  appendix,  545 
lateral  incision,    546 
relation,    543 
removal    of    appen- 
dix, 546 
treatment,  545 
tuberculous,    and    ap- 
pendicitis,   relation, 
544 
connective  tissue,  infection 
of,    vaginal   section    for, 
117 
hematocele  in  extrauterine 
pregnancy,  162 
treatment,  170 
infections,  rectal  infections, 
rectal      and      perirectal 
tissues,   relationship  be- 
tween, 466 


Pelvic  inflammations,  in  preg- 
nancy,    operations     for, 
115 
peritoneum,  drainage,  718 
suppuration,    vaginal    sec- 
tion for,  117 
surgery,  drainage  in,   712 
See     also     Drainage     in 
abdominal      and      pelvic 
surgery. 
veins,     thrombosis,     post- 
operative, 63 
Pelvis,  renal,  tumors  of,  810 
Penrose  and  Beyea's  method 

of  nephropexy,  828 
Peptic  ulcer  of  intestine,  419 
of  jejunum  after  gastro- 
enterostomy, 342 
Periappendical   abscess   from 

appendicitis,  520 
Periappendicitis,        suppura- 
tive, 520 
Pericarditis,     post-operative, 

11 
Perineal  hernia,  690 
Perinephric  fascia,  749 
Perinephritis,  799.     See  also 

Paranephritis. 
Periprocteal  hematocele,  466 
Peritoneal  adhesions  as  cause 
of      extrauterine      preg- 
nancy, 131 
cavity,    rupture    into,     in 
tubal  pregnancy,  153 
Peritoneoplasty,     prevention 
of  post-operative  intestinal 
adhesions  by,  463 
Peritoneum,     anatomy     and 
physiology,    with    refer- 
ence   to    peritoneal    ab- 
sorption    and     localiza- 
tion, 713 
drainage,  724 

ectropion  of,  prevention  of 
post-operative  intestinal 
adhesions  by,  463 
escape  of  pancreatic  juice 

into,  561 
pelvic,  drainage,  718 
tuberculosis,  617.     See  also 
Tuberculosis     of    perito- 
neum. 
Peritonitis,   diffuse   suppura- 
tive, abdominal  sec- 
tion for,  121 
Blake's    principles    of 
operative  treat- 

ment, 726 
continuous         entero- 
clysis  in  after-treat- 
ment, 727 
Fowler's    position    in, 
728 
drainage  in,  724 
generalized,  from  appendi- 
citis, 521 
treatment,  541 
post-operative,  general,  19 
acute,  19 
causes,  19 


Peritonitis,      post-operative, 
general,  acute,  di- 
agnosis, 21 
fibrinous       exudate 

in,  20 
Fowler's        position 

in,  23 
hemorrhagic       exu- 
date in,  20 
morbid  anatomy,  20 
Murphy's  treat- 

ment, 23 
prognosis,  21 
purulent        exudate 

in,  20 
sero-fibrinous     exu- 
date in,  20 
symptoms,  20 
treatment,  22 
local,  18 

treatment,  19 
purulent,     from     appendi- 
citis, 522 
septic,    from    appendicitis, 

521 
spreading,    from    appendi- 
citis, 521 
treatment,  541 
Peter's  operation  for  prolapse 

of  rectum,  503 
Petit's  triangle,  689 
Phlegmonous     paranephritis, 

800 
Phloridzin     test     in     kidney 

operations,  822 
Piles,  504.     See  also  Hemor- 
rhoids. 
Pilonidal  cysts,  infected,  459 
Placenta  in  tubal  pregnancy, 

147 
Pleurisy,  post-operative,  40 
Pneumonia  after  hernia  oper- 
ation, 666 
and  appendicitis,  differen- 
tiation, 531 
lobar,  post-operative,  37 
non-septic,  post-operative, 

37 
post-operative,  37 
treatment,  38 
Poisoning,  atropin-,  post-op- 
erative, 69 
by    drugs,    post-operative, 

69 
carbolic    acid-,    post-oper- 
ative, 70 
iodoform-,    post-operative, 

70 
mercury-,     post-operative, 

70 
opium-,  post-operative,  69 
strychnin-,   post-operative, 
69 
Polycystic  disease  of  kidney, 
812 
treatment,  814 
Polycythemia,   chronic,  with 
cyanosis       and       enlarged 
spleen,  599 
Polymazia,  193 


INDEX. 


857 


Polypi  of  vermiform  appen- 
dix, 554 

tubal,   as   cause   of   extra- 
uterine pregnancy, 131 
Porro-Cesarean    section,    80, 
98 
history,  98 
indications,  99 
instruments,  102 
technic,  102 
Portal  infection  complicating 
appendicitis,  523 

vein,      thrombosis,      post- 
operative, 68 
Post-mortem    Cesarean    sec- 
tion, 85,  86 
Post-operative  complications 
after  splenectomy,  602 

hernia,  686 

treatment,  687 

ileus,  415 

diagnosis,  416 
treatment,  417 
operative,  418 

infection  in  hemorrhoids, 
505 

intestinal    adhesions,    460. 
See  also  Intestinal   adhe- 
sions, post-operative. 
Post-rectal  cysts,  458 

fistula,  458 

congenital,  458 
Pregnancy,  abdominal,  158 

abscess  of  Bartholin's 
gland  in,  operation  for, 
115 

amputation  of  cervix  for 
hypertrophy  of  vaginal 
portion  in,  111 

appendicitis  in,  548 
operation  for,  106 
treatment,  549 

cancer  of  cervix  in,  opera- 
tion for,  115 
of  rectum  in,   operation 
for,  115 

cholecystitis  in,  operation 
for,  108 

combined  and  multiple,  164 

cysts  of  vulva  in,  operation 
for,  115 

dental  operations  in,116 

diffuse  bilateral  hyper- 
trophy in,  197 

diseases  of  urinary  tract  in, 
operation  for,  114 
of  vulva  in,  operation  for, 
115 

ectopic,  130 

effect  of  appendicitis  on, 
549 

extrauterine,    130.  See 

also     Extrauterine    preg- 
nancy. 

fibroid  tumors  of  uterus  in, 
operation  for,  109 

hematoma  of  vulva  in, 
operation  for,  115 

malignant  growths  in, 
operation  for,  115 


Pregnancy,  multiple,  164 

operations  during,  106 
management,  116 

ovarian,  137 
tumors  in,  112 
operation  for,  112 

pelvic     inflammations     in, 
operation  for,  115 

post-operative        manage- 
ment in,  116 

pyelitis   in,   operation   for, 
114 

pyonephrosis  in,  operation 
for,  114 

sub  -  peritoneo  -  abdominal, 
157 

sub-peritoneo-pelvic,  157 

tubal,  141.     See  also  Tubal 
pregnancy. 

tubo-abdominal,  157 

tubo-ovarian,  157 

tubo-uterine,  157 

ureteritis  in,  operation  for, 
114 

vaginal  fistula  in,  operation 
for,  113 
Premature   labor,   induction, 

80,  81,  82 
Pressure  paralysis,  post-oper- 
ative, 52 
Proctectomy,  sacral,  for  ma- 
lignant   tumors    of    rec- 
tum, 479 

vaginal,       in        malignant 
tumors  of  rectum,  481 
Proctoclysis  in  ileus,  414 
Proctoscopes,  Murphy's,  467 
Prolapse   of   Fallopian   tube, 
post-operative,  78 

of  pancreas,  575 
treatment,  575 

of  rectum,  496 
colopexy  in,  503 
diagnosis,  497 
Gant's    operation,     500, 

501 
Jeannel's  operation,   503 
Lang's  operation,  497 
Mikulicz's  operation,  499 
Murphy's  operation,  503 
pathology,  497 
Peters'  operation,  503 
Roberts'   operation,   498 
sigmoidopexy,  503 
treatment,  497 
Treves'  operation,  499 
Tuttle's    operation,    501 
Van    Buren's    cauteriza- 
tion, 497 
Verneuil's  operation,  500 
wire  operation,  500 

of  stomach,  370 
Pseudo-leukemia,  616 
Puberty       hypertrophy       of 

breast,  182,  194 
Puerperal  atrophy  of  tube  as 
cause      of     extrauterine 
pregnancy,  135 

sepsis,    abdominal    section 
for,  indications,  118 


Puerperal  sepsis,  exploratory 
abdominal  section  for, 
128 
hysterectomy  for,  123 
indications,  127 
technic,  127 
operative  treatment,  117 
routine  instrumental  ex- 
ploration and  evacua- 
tion of  uterus  for,  117 
salpingo  -  oophorectomy 

for,  122 
vaginal  section  for,   117 
Puerperium,         appendicitis 

complicating,  548 
Pulmonary      abscess,      post- 
operative, 41 
edema,  post-operative,  41 
embolism  complicating  ap- 
pendicitis, 523 
post-operative,  39,  65 
treatment,  66 
gangrene,     post-operative, 

41 
tuberculosis,         post-oper- 
ative, 41 
Pulse,      peculiarities,      after 

operations,  10 
Purpuric    rashes,    post-oper- 
ative, 69 
Purulent  peritonitis  from  ap- 
pendicitis, 522 
Pus  cells  in  stomach,  321 
Pyelitis  and  appendicitis,  dif- 
ferentiation, 531 
in     pregnancy,     operation 

for,  114 
post-operative,  48 
Pyelo-enteric  fistula,  448 

treatment,  449 
Pyelonephritis,  774 
ascending,  776 
symptoms  of,  778 
treatment,  781 
associated    with    calculus, 

792 
descending,  776 

treatment,  781 
diagnosis,  779 
pathologic  anatomy,  776 
prognosis,  781 
symptoms,  558 
treatment,  781 
Pyeloplication,  Israel's  oper- 
ation, 773 
Pyemia,    post-operative,    23, 
24 
treatment,  25 
Pylephlebitis       complicating 

appendicitis,  523 
Pyloroplasty,  .374 

Finney's  method,  375 

Gould's    modification, 
378 
Pylorus,  stenosis  of,  congeni- 
tal, gastro-enterostomy  for, 
327 
Pyonephrosis,  774 

in     pregnancy,     operation 
for,  114 


858 


INDEX. 


Pyonephrosis,        post-opera- 
tive, 48 
Pyopneumo-appendix,  520 
Pyoureter,  733 
Pyuria  post-operative,  49 


QuENu's  perineal  operation 
for  malignant  tumors  of 
rectum,  477 


Ranula  pancreatica,  569 
Rashes,    purpuric   post-oper- 
ative, 69 
Rectovaginal  fistula,  456 
treatment,  457 

Bureau  and  Vignard's 

method,  457 
Fritsch's  method,  457 
Rectum,  absence,  471 
adenoma,  472 
carcinoma,  474 

in  pregnancy,  operation 

for,  115 
metastases  in,  475 
treatment,  475 
chondroma,  473 
cysts,  473 
dermoids,  473 
examination,  466 
fibroma,  473 
fibromyoma,  473 
gunshot   wounds,   abstract 

of  literature,  650 
Hpoma,  473 
malformations,  468 
myoma,  473 

opening    into    neighboring 
organ,  469 
on  skin,  470 
osteoma,  473 
papilloma,  473 
persistence  of  septum,  468 
post-operative     adhesions, 

462 
prolapse,     496.     See     also 

Prolapse  of  rectum. 
sarcoma,  475 

metastases  in,  475 
treatment,  475 
stricture,     488.     See     also 

Stricture  of  rectum. 
tumors,  472 
benign,  472 

general  treatment,  474 
malignant,  474 

Kraske's       operation, 

479 
Quenu's    perineal    op- 
eration, 477 
radical  treatment,  475 
Rehn-Rydygier    oper- 
ation, 480 
vaginal        extirpation 

in,  481 
zinc   cauterization   in, 
475 


Reflex  ileus,  394 

symptoms,  404 
Regurgitant    vomiting    after 

gastro-enterostomy,  340 
Rehn-Rydygier  operation  for 
malignant   tumors   of   rec- 
tum, 480 
Renal  artery,  751 
Repair,  intestinal,  429 
Retention     of     urine,     post- 
operative, 42,  46 
treatment,  48 
Retraction  of  nipple  as  sign 

of  cancer  of  breast,  186 
Retrocecal  recess,  hernia,  693 
Retroperitoneal       appendix, 

removal,  537 
Retro-uterine        hematocele, 

466 
Retrovesical    recess,    hernia, 

694 
Ricketts'  method  of  hgation 

in  hemorrhoids,  511 
Roberts'    operation   for   pro- 
lapse of  rectum,  498 
Robson's  bone  bobbin,  433 
incision  in  gall-bladder  and 
gall-duct       operation, 
296 
in  operations  on  kidney, 
818 
operation  for  incontinence 
of  feces   after  operation 
for  fistula  in  ano,  496 
position     for     gall-bladder 
and  gall-duct  operation, 
295 
Rontgen  rays  in  diagnosis  of 

renal  calculus,  795 
Round  duodenal  ulcer,  419 
Roux's    method    of    gastro- 
enterostomy, 338 
Rovsing's  method  of  gastro- 

pexy,  374 
Rudimentary  kidney,  753 
Rupture,    arterial,    of   brain, 
post-operative,  67 
extra  tubal,  in  tubal  preg- 
nancy, 153 
into     broad     ligament     in 

tubal  pregnancy,  156 
into    peritoneal    cavity    in 

tubal  pregnancy,  153 
intra  tubal,   in   tubal   preg- 
nancy, 150 
of  kidney,  755 

treatment,  758 
of  spleen,  609 

splenectomy  in,  610 
Ruptured  extrauterine  preg- 
nancy    and     appendicitis, 
differentiation,  544 


Sac  wall,  structure,  in  tubal 

pregnancy,  148 
Sacculated  kidney,  782 

treatment,  782 
Sac-kidney  of  Kiister    765 


Sacral  proctectomy  for  malig- 
nant tumors  of  rectum,  479 
Sago-spleen,  615 
Salpingitis  as  cause  of  extra- 
uterine pregnancy, 131 
Salpingo-oophorectomy      for 

puerperal  sepsis,  122 
Sapremia,  post-operative,  17 
Sarcinse  in  stomach,  321 
Sarcoma  of  breast,  248 
classification,  249 
in  intracanalicular  myx- 
oma, 249 
metastatic,  251 
modified   operation,   274 
primary  non-indigenous, 
250 
of  intestine,  428 
of  kidney,  805 
of  pancreas,  treatment,  592 
of  rectum,  475 
metastases  in,  475 
treatment,  475 
of  spleen,  614 

splenectomy  in,  614 
of     vermiform     appendix, 
554 
Sarcomatous  cysts  of  breast, 

247 
Sbanajew-Franck's      method 

of  gastrostomy,  366 
Scalding    of    esophagus    and 
stomach,  gastrostomy  for, 
366 
Sciatic  hernia,  690 
Scirrhous  carcinoma  of  breast 
240 
atrophic,  246 
circumscribed,  245 
Secondary       anemia        with 

splenic  tumor,  598 
Semilunar  incision  in  appen- 
dicitis, 534 
Senile  breast,  185 
Senn's  bone  plate,  433 

method     of     gastrostomy, 
368 
of  nephropexy,  828 
of    omental    grafting    in 
intestinal  anastomosis, 
439 
Sepsis,    puerperal,    operative 
treatment,    117.     See  also 
Puerperal  sepsis 
Septic  ileus,  396 
symptoms,  405 
peritonitis    from    appendi- 
citis, 521 
Septicemia,      post-operative, 
23,  24 
treatment,  24 
Shield-shaped  kidney,  753 
Shock  after  operations,  1 
treatment,  2 
delayed,  after  operations,  1 
Side-to-side  intestinal  anasto- 
mosis, 439 
Sigmoid,  examination,  466 
post-operative     adhesions, 
462 


INDEX. 


859 


Sigmoidopexy  in  prolapse  of 

rectum,  503 
Sigmoidorectostomy  in  stric- 
ture of  rectum,  491 
Sloughing  of  abdominal  wall, 

post-operative,  55 
Spastic  ileus,  post-operative, 
32 
treatment,  33 
Spinal    cord,    injuries,    ileus 

from,  394 
Spleen,  abscess,  612 

treatment,  613 
ague-cake,  607 

splenectomy  for,  607 
amyloid,  615 

angioma   cavernosum,   615 
arterial     embolism,     post- 
operative, 68 

thrombosis,      post-oper- 
ative, 68 
cysts,  611 

treatment,  611 
diseases,  diagnosis,  598 
displaced,  604 

operations  for,  604 
echinococcus  cysts,  612 

treatment,  612 
excision,  partial,  596 
functions,     performed     by 

other  organs,  596 
gunshot  wounds,  611 
hernia,  611 
hypertrophy,  606 

in  infancy,  609 
injuries,  609 
injuries  to,  in  penetrating 

wounds      of      abdomen, 

treatment,  643 
malarial  hypertrophy,  607 

splenectomy  for,  607 
operations  on,  595 

contraindications,  598 

diagnosis,  598 

indications,  596 
rupture,  609 

splenectomy  in,  610 
sago-,  615 
sarcoma,  614 

splenectomy  in,  614 
suspension,  596 
suture,  596 
syphilis,  615 

treatment,  615 
tuberculosis,  613 

splenectomy  in,  613 
■wandering,  604 

operations  for,  604 

splenectomy  in,  606 

splenopexy  in,  606 

twisted  pedicle  in,  605 
wounds,  609 
Splenectomy,  596,  600 

for    malarial    hypertrophy 

of  spleen,  607 
in  Banti's  disease,  608 
in  rupture  of  spleen,  610 
in  sarcoma  of  spleen,  614 
in  splenic  leukemia,  616 
in  tuberculosis  of  spleen,  613 


Splenectomy     in    wandering 
spleen,  606 
indications,  596,  597 
ligation  of  pedicle,  601 
mortality,  597 
technic,  600 
Splenic  leukemia,  6^ 

splenectomy  in,  616 
vessels,  ligation,  596 
Splenopexy,  596 

in  wandering  spleen,  606 
Spoon,  gall-stone,  298 
Stab  wounds  of  kidney,  754 
symptoms,  756 
treatment,  758 
Stenosis     of     pylorus,     con- 
genital, gastro-enteros- 
tomy  for,  327 
Stercoral  ulcer,  422 
Stomach,  bacteria  in,  321 
blood  in,  chemical  test,  320 
body  of,  carcinoma,  361 
carcinoma,   351.     See  also 

Carcinoma  of  stomach. 
cardiac  end,  cancer,  361 

gastrostomy  for,  365 
contents,   amount   of   resi- 
due visible  to  naked  eye 
in,  320 
dilatation,  325 

acute,  post-operative,  33 
treatment,  34 
diseases,     examination     of 

blood  in,  321 
drainage,  724 
epithelial  cells  in,  321 
foreign   bodies  in,  gastrot- 

omy  for,  361 
fragments  of  tissue  in,  321 
free  HCl  in,  test  for,  320 
hernia,  661 
hour-glass,   345.     See   also 

Hour-glass  stomach. 
interior,     gastrotomy     for 

exploration,  363 
lactic  acid  in,  320 
lymphatic  areas,  354 
mucous  membrane,   corro- 
sion, gastro-enteros- 
tomy  for,  326 
operations  upon,  318 
investigation  in,  318 
preparatory     treatment, 
318 
pedunculated     tumors     of 

gastrotomy  for,  364 
penetrating    wounds,     ab- 
stract of  literature, 
649 
gastrorrhaphy  in,  ab- 
stract of  literature, 
650 
prolapse,  370 
pus  cells  in,  321 
sarcinse  in,  321 
scalding,   gastrostomy  for, 

366 
symptoms    of    gall-stones, 

283 
tests,  320 


Stomach,  ulcer,  323 

acute,        gastro-enteros- 

tomy  for,  323 
chronic,        gastro-enter- 

ostomy  for,  323 
gastro-enterostomy    for, 

323,  326 
pain  as  symptom,  324 
symptoms,  324 
tenderness  as  symptom, 

325 
vomiting    as    symptom, 
325 
yeast  in,  321 
Strangulated  hernia,  399,  663 
course,  410 
diagnosis,  408 
elastic,  664 
fecal,  664 
symptoms    and    course, 

410,664 
treatment,  668 
Stricture   after   reduction   of 
hernia,  666 
of  esophagus,  gastrostomy 
for,  365 
assisting  in  dilatation, 
364 
of  rectum,  488 

Bacon's    operation,    490 

dilatation  in,  490 
sacral       colorectostomy, 

sigmoidorectostomy,  491 
symptoms,  489 
treatment,  490 
varieties,  488 
of  ureter,  733 

operative  treatment,  743 

Stroma        interlobular,        of 

breast,  182 

intralobular,  of  breast,  182 

Strychnin,      poisoning      by, 

post-operative,  69 
Subcapsular       nephrectomy, 

836 
Subperitoneo     -     abdominal 

pregnancy,  157 
Subperitoneo-pelvic         preg- 
nancy, 157 
Subphrenic  abscess,  314 

complicating       appendi- 
citis, 522 
treatment,  540 
diagnosis,  316 
prognosis,  316 
symptoms,  315 
treatment,  317 
Supernumerary  breast,  193 

kidney,  753 
Suppression    of    urine    post- 
operative, 42,  46 
treatment,  48 
Suppuration,  pelvic,  vaginal 

section  for,  117 
Suppurative   pancreatitis, 567 
symptoms,  567 
treatment,  580 
periappendicitis,  520 


860 


INDEX. 


Suppurative  peritonitis,   dif- 
fuse, abdominal  section  for, 

121 
Suspension  of  spleen,  596 
Suture,    Brodel's,  in  nephro- 
pexy, 827 

Connell's,  431 

Cushing's,  431 

Czerny-Lembert,  431 

Dupuytren's,  431 

Halsted's,  431 

intestinal,  430 

Lembert's,  430 

of  spleen,  596 

Wolfler's  intestinal,  431 
Symphysiotomy,  80,  81,  84, 

85 
Syphilis  of  intestine,  427 

of  pancreas,  591 
treatment,  591 

of  spleen,  615 
treatment.  615 

post-operative,  73 
Syphilitic    fever,     post-oper- 
ative, 73 

lesions  of  nipple,  253 

mastitis,  212 


Tabetic     crises     and     ileus, 

differentiation,  397 
Tachycardia,   post-operative, 

10 
Tsenia  echinococcus,  311 
Temperature    angle    of    cho- 

langic  infections,  285 
Test,  chemical,  for  blood  in 
stomach,  320,  322 
for   free   HCl   in   stomach, 

320 
for  lactic  acid  in  stomach, 

320 
indigo-carmin,     in    kidney 

operations,  821 
phloridzin,  in  kidney  oper- 
ations, 822 
stomach,  320 
Thrombosis,    arterial,    of   in- 
testine, post-oper- 
ative, 66 
of    spleen    and    kidney, 

post-operative,  68 
post-operative,  61 
complicating    appendicitis, 

523 
intestinal  ulcers  from,  425 
of     coronary     arteries     of 
heart,  post-operative,  67 
of  femoral  vein,  post-oper- 
ative, 63 
of  pelvic  veins,  post-oper- 
ative, 63 
of  portal   vein,   post-oper- 
ative, 68 
post-operative,  59 
prognosis,  64 
symptoms,  63 
treatment,  64 


Thrombosis,    venous,    of   in- 
testine, post-operative, 
66 
of    spleen    and    kidney, 

post-operative,  68 
post-operative,  61 
Torsion  of  intestine,  399 
of  omentum,  394 
diagnosis,  396 
pathologic  anatomy,  395 
symptoms,  410 
treatment,  396 
Towel    method    of    replacing 
bowels  after  operation  for 
ileus,  413 
Toxic  ulcers  of  intestine,  425 
Transperitoneal     incision    in 
operations  on  kidney,  820 
Treitz's  hernia,  692 
Treves'  operation  for  prolapse 

of  rectum,  499 
Trigonum    lumbale    inferius, 
689 
superius,  689 
Trocar    for    aspirating    gall- 
bladder, 297 
Truss  in  treatment  of  hernia, 

666 
Tubal  abortion,  150 
pregnancy, 141 
decidua  in,  144 

reflexa  in,  146 
extratubal     rupture     in, 

153 
intratubal    rupture,    150 
mode  of  implantation  of 

o^'um  in,  142 
placenta  in,  147 
repeated,  164 
rupture  into  broad  liga- 
ment in,  156 
into  peritoneal  cavity 
in,  153 
structure  of  sac  wall  in, 

148 
terminations,  150 
uterine   decidua   in,   149 
Tubercular  mastitis,  211 
Tuberculin     preparations    in 
tuberculosis  of  peritoneum, 
637 
Tuberculosis,    acute   miliary, 
of  peritoneum,  623 
of  breast,  211 
of  hernia  sac,  666 
of  kidney,  783 

age  occurring,  783 
diagnosis,  786 
frequency   783 
pathology,  784 
prognosis,  789 
sex  occurring,  783 
symptoms,  785 
treatment,  789 
of  pancreas,  591 
treatment,  591 
of  pelvic  organs  in  female, 
and    appendicitis,    rela- 
tion, 544 
of  peritoneum,  617 


Tuberculosis   of   peritoneum, 
acute,  623 
miliary,  623 
symptoms,  624 
age  occurring,  620 
Bottomley's    method    of 

treating,  636 
chronic,  623 
fibrous,  624 
symptoms,  625 
ulcerative,  623 
diagnosis,  626 

differential,  627 
etiology,  619 
factors  governing  infec- 
tion, 621 
Giuldjide's     method     of 

treating,  636 
historical,  617 
incidence,  619 
latent,  symptoms,  624 
Mayo's  method  of  treat- 
ing, 635 
Neff's  method   of  treat- 
ing, 636 
Ochsner's      method      of 

treating,  636 
pathology,  623 
prognosis,  628 

as  affected  by  medical 
treatment,  631 
by     surgical     treat- 
ment, 629 
sex  occurring,  620 
subacute,  625 
symptoms,  624 
treatment,  633 
medicinal,  637 
operative,    indications 
and  contraindica- 
tions, 633 
technic,  634 
tuberculin    preparations 
in,  637 
of  spleen,  613 

splenectomy  in,  613 
of  ureter,  733.  734 

operative  treatment,  743 
of     vermiform     appendix, 
552 
treatment,  553 
pulmonary,  post-operative, 
41 
Tuberculous  salpingitis  open- 
ing into  rectum.  465 
ulcer  of  intestine.  423 
symptoms.  425 
Tubo-abdominal    pregnancy, 

157 
Tubo-ovarian  pregnancy,  157 
Tubo-uterine  pregnancy,  157 
Tumors,  adrenal,  811 
as  cause  of  ileus,  399 
benign,  of  breast.  212 
epithelial,  benign,  of  breast, 

220 
fibro-epithelial,    of   breast, 

214 
fibroid,  of  uterus,  in  preg- 
nancy, operation  for.  109 


INDEX. 


861 


Tumors,     infected,     opening 
into  rectum  and  sigmoid, 
465 
malignant,  of  areola,  253 
of  breast,  diagnosis,  185 
pain,       discharge      of 
blood    from    nipple, 
and    fluctuation    in 
diagnosing,  187 
multiple,  of  breast,  214 
of  breast,  age  of  onset,  189 
and    lactation    mastitis, 

differentiation,  190 
clinical  picture,  185 
cystic,  246 
diagnosis,  185 
duration,  189,  190 
excision  of  breast,  258 

of  tumor,  257 
exploratory   incision   for 

diagnosis,  257 
important    facts    to    be 
ascertained  in  history, 
189 
lactation  hypertrophy  of 
breast  and,  differentia- 
tion, 190 
multiple,  excision,  257 
Warren's       operation, 
257 
operative  technic,  256 
position,  189 
preparations    for   opera- 
tion, 256 
symptoms  of  onset,  191 
trauma       as       etiologic 
factor,  190 
of  Fallopian  tube  as  cause 
of      extrauterine      preg- 
nancy, 131 
of  intestine,  427 
benign,  427 
malignant,  427 
of  kidney,  803 
benign,  804 
cystic,  811 
diagnosis,  809 
malignant,  805 
mixed,  805 
prognosis,  809 
solid,  804 
symptoms,  807 

urine,  808 
treatment,  809 
of  pancreas,  treatment,  591 
of  rectum,  472 
benign,  472 

general  treatment,  474 
malignant,  474 

abdomino    -    perineal 

operation,  486 
general  treatment,  475 
Kraske's        operation, 

479 
Qu^nu's  perineal  oper- 
ation, 477 
radical  treatment,  475 
Rehn       -      Rydygier 
method,  480 


Tumors    of    rectum,    malig- 
nant, vaginal  extir- 
pation of  rectum ,  48 1 
zinc    cauterization    in, 
475 
of  renal  pelvis,  810 
of  vermiform  appendix,  554 

treatment,  556 
ovarian,  in  pregnancy,  112 
operation  for,  112 
with  twisted  pedicle,  and 
appendicitis,    differen- 
tiation, 544 
pararenal,  811 
pedunculated,  of  stomach, 

gastrotomy  for,  364 
single,  small,  of  breast,  217 
of  breast,  216 
Tuttle's    operation    for    pro- 
lapse of  rectum,  501 
Twin  ova,  obstruction  by,  as 
cause  of  extrauterine  preg- 
nancy, 135 
Twisted  pedicle  in  wandering 

spleen,  605 
Tympanites,    post-operative, 
9 
treatment,  10 
Typhoid  fever  and  appendi- 
citis,     differentiation, 
531 
appendicitis  in,  550 
symptoms    and    diag- 
nosis, 551 
treatment,  551 
post-operative,  71 
ulcer,  422 


Ulcer,    catarrhal,    of    intes- 
tine, 422 
decubital,  of  intestine,  422 
dysenteric,  423 
excision,  344 

follicular,  of  intestine,  422 
of  duodenum,  419 
course,  421 
round, 419 
symptoms,  421 
treatment,  422 
of  intestine,  419 
from  anthrax,  424 
from  burns,  424 
from       embolism       and 

thrombosis,  425 
from  uremia,  425 
of  stomach,  323 

acute,        gastro-enteros- 

tomy  for,  323 
chronic,     gastro-enteros- 

tomy  for,  323 
gastro-enterostomy    for, 

323,  326 
pain  as  symptom,  324 
symptoms,  324 
tenderness  as  symptom, 

325 
vomiting    as    symptom, 
325 
peptic,  of  intestine,  419 


Ulcer,    peptic,    of    jejunum, 
after  gastro-enteros- 

tomy, 342 
round,   of  duodenum,   419 
stercoral,  422 
toxic,  of  intestine,  425 
tuberculous,    of    intestine, 

symptoms,  425 
typhoid,  422 
Ulcus  duodeni  pepticum,  419 
Umbilical  hernia,  680 

Mayo's  operation,  684 
Urea,        determination        of 
amount,   in  operations  on 
kidney,  821 
Uremia,      intestinal      ulcers 

from,  425 
Uremic  ileus,  396 

symptoms,  407 
Ureter,  calculus,  733 

and  appendicitis,  differ- 
entiation, 531 
operative  treatment,  739 
catheterization,   in  kidney 

operations,  821 
fistula,  733 

congenital,       treatment, 

739 
post-operative,  51 
treatment,  738 
injuries,  734 
malignant  disease,  733 

treatment,  745 
stricture,    733 

operative  treatment,  743 
surgery,  732 
surgical  lesions,  732 
causes,  733 
diagnosis,  733 
treatment,   early,   735 
late,  736 
tuberculosis,  733,  734 

operative  treatment,  743 
wounds,  734 
Ureteral  dilators,  741 
Ureteritis  in  pregnancy,  oper- 
ation for,  114 
Urinalysis     in     appendicitis, 

530 
Urinary    tract,    diseases,    in 
pregnancy,     operation 
for,  114 
post-operative  intestinal 
adhesions,  462 
Urine,  cryoscopy,   in  kidney 
operations,  822 
incontinence         post-oper- 
ative, 43 
retention,     post-operative, 
42,  46 
treatment,  48 
Uronephrosis,  765 
Urticaria,   post-operative,  69 
Uterine     adnexa,     drainage, 
718 
decidua  in  tubal  pregnancy, 
149 
Uterus,  drainage,  718 

fibroid    tumors,    in    preg- 
nancy, operation  for,  109 


862 


INDEX. 


Uterus,  hernia,  659 

routine  instrumental  ex- 
ploration and  evacua- 
tion, for  puerperal  sep- 
sis, 117 


Vaginal  extirpation  of  rec- 
tum in  malignant  tumors, 
481 
fistula  in  pregnancy,  opera- 
tion for,  113 
portion     of     cervix    uteri, 
hypertrophy,       amputa- 
tion  for,   in   pregnancy, 
111 
puncture  of  pelvic  abscess, 

drainage  after,  720 
section     for     infection     of 
pelvic  connective 

tissue,  117 
for    pelvic    suppuration, 

117 
for  puerperal  sepsis,  117 
Van  Buren's  cauterization  in 

prolapse  of  rectum,  497 
Van  Hook's  method  of  end- 
to-side       anastomosis       of 
upper   end   of   ureter   into 
lower,  739 
Vascular   supply    of   kidney, 
relation,   to   kidney   pelvis 
and  calyces,  750 
Vein,  femoral,  thrombosis  of, 
post-operative,  62,  63 
pelvic,  thrombosis  of,  post- 
operative, 63 
portal,  thrombosis  of,  post- 
operative, 68 
Venous  embolism  of  intestine, 
post-operative,  66 
of    spleen    and    kidney, 
post-operative,  68 
thrombosis     of     intestine, 
post-operative,  66 
of    spleen    and    kidney, 

post-operative,  68 
post-operative,  61 
Ventral  hernia,  684 
Vermiform  appendix,  actino- 
mycosis, 553 
treatment,  554 
adherent,    removal,    537 
anatomy  and  physiology, 

516 
carcinoma,  555 

treatment,  556 
diseases,  519 

operations  for,  514 
diverticula,  523 
drainage,  721 
effected  in  amebic  dysen- 
tery, 554 
fibroma,  554 
function,  517 
hernia,  556 
treatment,  556 


Vermiform  appendix,  inflam- 
matory diseases,  550 
lipoma,  554 
myoma,  554 
myxoma,  554 
polypi,  554 

removal,  in  appendicitis, 
535 
ligation    of    mesen- 
tery, 535 
treatment  of  stump, 
535 
retroperitoneal  removal, 

537 
sarcoma,  554 
topography,  518 
tuberculosis,  552 
treatment,  553 
tumors,  554 
treatment,  556 
Verneuil's  operation  for  pro- 
lapse of  rectum,  500 
Virginal  gastroptosis,  370 
hypertrophy,     diffuse,     of 
breast,  197 
Volvulus,  399 

post-operative,  27 
symptoms,  409 
Vomiting,  cyclic,  in  children, 
acid  intoxication  in,  13 
post-operative,  7 

treatment,  8 
regurgitant,    after    gastro- 
enterostomy, 340 
Von  Eiselsberg's  sign  in  hour- 
glass stomach,  346 
Vulva,   cysts,   in   pregnancy, 
operation  for,  115 
diseases,  in  pregnancy,  op- 
eration for,  115 
hematoma,    in   pregnancy, 
operation  for,  115 


Wandering  spleen,  604 
operations  for,  604 
splenectomy  in,  606 
splenopexy  in,  606 
twisted  pedicle  in,  605 
Warren's  operation  for  multi- 
ple tumors  of  breast,  257 
Weir  and   Foote's   operation 
for  hour-glass  stomach,  347 
Weir's  operation  of  appendi- 

costomy,  542 
Whitehead's     operation     for 
hemorrhoids,  509 
Earl's       modification, 
510 
Winslow^s     foramen,     hernia 

into,  693 
Wire  operation  for  prolapse 

of  rectum,  500 
Witzel's  method   of  gastros- 
tomy, 367 
Wolfler's   first  sign  of  hour- 
glass stomach,  346 


Wolfler's     intestinal    suture, 
431 
second   sign   of   hour-glass 
stomach,  346 
Wound  fever,  aseptic,  15 
Wounds,  erysipelas  of,  post- 
operative, 18 
foreign  bodies  left  in,  58 
gunshot,  of  kidney,  754 
symptoms,  756 
treatment,  758 
of    rectum,    abstract    of 

literature,  650 
of  spleen,  611 
of  kidney,  754 
etiology,  754 
gunshot,  754 
symptoms,  756 
treatment,  758 
in  penetrating  wounds  of 
abdomen,     treatment, 
644 
incised      or     punctured, 

treatment,  758 
pathology,  754 
penetrating,  754 
prognosis,  757 
stab,  754 

symptoms,  756 
treatment,  758 
symptoms,  756 
treatment,  757 
.    of  liver,  312 

Franck's  operation,  314 
treatment,  312 
of  pancreas,  576 
diagnosis,  576 
treatment,  577 
of  spleen,  609 
of  ureter,  734 

penetrating,    of    abdomen, 

639.         See    also    .46- 

domen,  penetrating 

wounds. 

of   bladder,    abstract   of 

literature,  650 
of      intestine,     enteror- 
rhaphy     in,     abstract 
of  literature,  650 
of    large    intestine,    ab- 
stract    of     literature, 
650 
of    small    intestine,    ab- 
stract    of     literature, 
649 
of  stomach,  abstract  of 
literature,  649 
gastrorrhaphy  in,  ab- 
•     stract  of  literature, 
650 


Yeast  in  stomach,  321 

Zinc  cauterization  in  malig- 
nant tumors  of  rectum,  475 


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